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56 Lampiran 1. Surat Izin Penelitian
57 Lampiran 2. Sertifikat Ethical clearance
58 Lampiran 3. Lembar Hasil Penelitian
No Inisi al
J K
Usi a
Riwayat penyaki
t lain
Riwayat penggunaan obat (bulan sebelumnya)
Tgl Periksa TD Nama obat R/ pill
count
Penyebab DRPS
Nama obat dosis
Keluha
n Indikas
i tanpa obat
Obat tanpa indikas
i
Obat salah
Dosis obat kurang
Reaksi obat merugika
n
Dosis obat lebih
kepatuha n
1 M
L 64 Amlodipin 5
mg 1x1 10/04/21 160/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 21/4/2021 150/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 25/5/2021 140/90 Amlodipin 5 mg 100
Amlodipin 10
mg 1x1 03/06/21 160/190 Amlodipin 10
mg X X X X X
Amlodipin 5
mg 1x1 03/08/21 230/130 Amlodipin 10
mg Amlodipin 5
mg 1x1 31/08/21 136/84 Amlodipin 5 mg OK6
2 DB
P Amlodipin 5
mg 1x1 04/05/21 160/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 04/06/21 150/80
Amlodipin 5 mg, Allopurinol,
Vitamin B6 Asam
urat
Amlodipin 5 mg, Allopurinol, Vitamin B6
1x1 02/07/21 160/80 Amlodipin 5
mg, Allopurinol 100 X X X X X
Asam urat
Amlodipin 5
mg, Allopurinol 1x1 03/08/21 160/80 Amlodipin 5 mg
Amlodipin 5
mg 1x1 30/8/2021 154/86
Amlodipin 5 mg, Allopurinol,
Simvastatin
OK6
3 HS
P Amlodipin 5
mg 1x1 07/05/21 150/100
Amlodipin 5 mg, Ibuprofen,
Vitamin B1
31/08/21 140/90 Amlodipin 5 mg
Amlodipin 5 mg, Omeprazole,
100 X X X X X X
59
Antasida, Na.
Diclofenac, GG Amlodipin 5
mg, Omeprazol,
Antasida
4 ML
L 45 01/03/19 190/130 Amlodipin 10
mg, Amlodipin 10
mg, 1x1 15/3/2021 180/120 Amlodipin 10
mg, Furosemid Amlodipin 10
mg, Furosemid 1x1 31/8/2021 280/130 Amlodipin 10
mg OK7
5 MS P 61 20/01/2017 150/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 12/05/18 180/80 Amlodipin 5 mg X X X X X X
Amlodipin 5
mg 1x1 09/01/21 190/90 Amlodipin 5 mg 75 KP1
6 TT
P 68 Amlodipin 5
mg 1x1 16/3/2020 140/80 Amlodipin 5 mg
Amlodipin 5
mg 1x1 25/07/20 140/70 Amlodipin 5 mg
Amlodipin 5
mg 1x1 01/07/21 160/90 Amlodipin 5 mg 100 X X X X X X
Amlodipin 5
mg 1x1 31/7/2021 Amlodipin 10
mg
7 HP P 52 09/04/17 160/110 Amlodipin 5 mg
Amlodipin 5
mg 1x1 23/05/17 140/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 06/06/17 150/100 Amlodipin 5 mg OK6
8 S L 55 20/2/2017 140/100 Nifedipin
Nifedipin 1x1 23/5/2017 150/100 Nifedipin 100
Nifedipin 1x1 04/08/20 200/120 Nifedipin 10 mg OS2
9 AL
P 71 Amlodipin 5
mg 1x1 31/8/2020 140/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 02/10/20 130/90 Amlodipin 5 mg 75
Amlodipin 5
mg 1x1 22/12/2020 120/80 Amlodipin 5 mg
60
Amlodipin 5
mg 1x1 29/2/2021 130/90 Amlodipin 5 mg KP1
10 ML L 61 Amlodipin 5
mg 13/9/2021 160/80 Amlodipin 5 mg 100 X X X X X X
11 PB L 25/1/2019 160/100 Amlodipin 5 mg
Amlodipin 5
mg 1x1 06/02/19 140/100 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 19/2/2019 130/90
12 E
P 70 Amlodipin 5
mg 1x1 07/03/20 180/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 09/06/21 170/80 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 02/07/21 180/80 Amlodipin 5 mg OK6
13 TS
P Amlodipin 5
mg 1x1 31/1/2020 150/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 26/3/2020 140/90 Amlodipin 5 mg 80
Amlodipin 5
mg 1x1 08/04/21 160/90 Amlodipin 5 mg KP1
14 M P 08/02/21 160/100 Amlodipin 5 mg 100
15 HS
P 54 Amlodipin 5
mg 1x1 02/05/21 150/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 03/05/21 110/60 Amlodipin 5 mg
Amlodipin 5
mg 1x1 04/05/21 200/100 Amlodipin 5 mg
Amlodipin 5
mg 1x1 28/5/2021 140/80 Amlodipin 10
mg 100
Amlodipin 10
mg 1x1 08/06/21 130/80 Amlodipin 5 mg OK7
16 JS
L 66 Amlodipin 5
mg 1x1 31/1/2019 120/20 Amlodipin 5 mg
17 MR
P Amlodipin 5
mg 1x1 04/04/20 180/100 Amlodipin 5 mg OK6
Amlodipin 5
mg 1x1 03/07/21 200/100 Amlodipin 10
mg 100
Amlodipin 10
mg 1x1 31/7/2021 160/100 Amlodipin 5 mg
61
Amlodipin 5
mg 1x1 20/8/2021 170/100 Amlodipin 5 mg
18 JTL L 57 Amlodipin 5
mg 1x1 21/12/2020 140/80 Amlodipin 5 mg
Amlodipin 5
mg 1x1 23/6/21 140/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 28/8/2021 140/90 Amlodipin 5 mg
19 YRL
P 68 Amlodipin 5
mg 1x1 08/10/17 140/100 Nifedipin
Nifedipin 1x1 13/11/2017 140/100 Amlodipin
20 YRT
P 51 Amlodipin 5
mg 1x1 08/06/21 170/110 Amlodipin 5 mg 75 KP1
21 AR L 51 Amlodipin 1x1 08/09/21 140/77 Livron 100
22 AK P 67 08/06/21 200/100 Amlodipin 5 mg 100 OS2
23 L
L 72
Amlodipin 5 mg, ciprofloxacin
1x1 15/7/2020 130/70 Amlodipin 5 mg 100
24 PP P 78 Amlodipin 5
mg 1x1 26/08/21 170/70 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 28/08/21 160/80 Amlodipin 5 mg
25 AK P 59 Nifedipin 1x1 04/04/20 150/80 Amlodipin 5 mg
Amlodipin 5
mg 1x1 19/7/2021 140/80 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 18/8/2021 150/90 Amlodipin 5 mg OK6
26 YL L 52 Amlodipin 10
mg 1x1 23/06/21 160/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 17/5/2021 160/100 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 08/02/21 130/90 Amlodipin 5 mg
27 LM
L 63 Amlodipin 5
mg 1x1 08/06/21 180/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 08/12/21 150/90 Amlodipin 5 mg
28 WS
L 75 Amlodipin 5
mg 1x1 13/1/2021 160/90 Amlodipin 5 mg
62
Amlodipin 5
mg 1x1 22/6/2021 180/110 Amlodipin 5 mg
Amlodipin 5
mg 1x1 21/7/2021 140/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 20/8/2021 130/80 Amlodipin 5 mg
29 PS
L 76 Amlodipin 5
mg 1x1 23/5/2018 130/90 Amlodipin 5 mg 100
30 P
L Amlodipin 100
mg 1x1 18/8/2020 170/70 Amlodipin 10
mg Amlodipin 10
mg 1x1 21/1/2021 203/83 Amlodipin 10
mg 100
Amlodipin 10
mg 1x1 11/02/21 180/90 Amlodipin 10
mg Amlodipin 10
mg 1x1 15/7/2021 160/70 Amlodipin 10
mg
31 JP L 79 Captopril 1x1 29/11/2014 150/100 Captopril
Captopril 1x1 10/12/14 150/100 Amlodipin 100
Amlodipin 1x1 19/12/2014 120/110 Amlodipin
32 PP
L 42 Amlodipin 5
mg 1x1 26/11/2020 138/90 Amlodipin 5 mg 100
33 R L 31 Nifedipin 1x1 15/5/2021 150/90 Nifedipin
Nifedipin 1x1 14/6/2021 150/100 Nifedipin 100
Nifedipin 1x1 14/7/2021 150/100 Nifedipin OK1
34 MPP
P 53 Amlodipin 5
mg 1x1 28/5/2021 120/80 amlodipin 5 mg
Amlodipin 5
mg 1x1 16/7/2021 120/80 amlodipin 5 mg 100
35 AD
P 44 Amlodipin 5
mg 1x1 08/10/21 190/130 Amlodipin 5 mg 100
36 HR L 65 Amlodipin 1x1 25/3/2021 170/90 Amlodipin
Amlodipin 1x1 24/4/2021 139/95 Amlodipin 100
37 BL
L 78 Amlodipin 5
mg 1x1 20/8/2021 140/83 Amlodipin 5 mg 100
38 S P 58 08/06/21 190/110 Amlodipin 5 mg 100 OK1
39 L P 61 Nifedipin 1x1 12/03/21 140/60 Nifedipin
63
Nifedipin 1x1 27/4/2021 160/90 Amlodipin 100 OK7
40 BL
L 68 Amlodipin 5
mg 1x1 28/12/2020 136/87 Amlodipin 5 mg
Amlodipin 5
mg 1x1 25/2/2021 130/80 Amlodipin 10
mg 100
41 DL P 56 08/07/21 200/110 Amlodipin 5 mg 100 OK6
42 MB
P 73 Amlodipin 5
mg 1x1 03/11/21 150/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 31/5/2021 160/100 Amlodipin 5 mg
Amlodipin 5
mg 1x1 26/6/2021 120/70 Amlodipin 5 mg
43 DT
L 51 Amlodipin 5
mg 1x1 17/6/2021 130/90 Amlodipin 5 mg 100
44 PP
P 51 Asam
urat
Amlodipin 10
mg 1x1 20/8/2021 120/90 Amlodipin 10
mg, Allopurinol 100
45 AP
L Amlodipin 10
mg 1x1 06/11/21 180/110 Amlodipin 10
mg 100
Amlodipin 5
mg 1x1 Amlodipin 5 mg
46 DP
L 62 Amlodipin 1o
mg 1x1 17/5/2021 200/110 Amlodipin 10
mg Amlodipin 10
mg 1x1 12/06/21 170/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 02/07/21 110/100 Amlodipin 5 mg
47 BL
P 53 Amlodipin 5
mg 1x1 22/4/2021 180/100 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 09/06/21 170/90 Amlodipin 10
mg
48 S L 81 Amlodipin 5
mg 1x1 19/6/2021 160/70 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 Amlodipin 5 mg
49 L
L Amlodipin 5
mg 1x1 30/6/2021 120/70 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 05/08/21 110/70 Amlodipin 5 mg
50 LL P 47 Amlodipin 5
mg 1x1 13/12/2019 130/80 Amlodipin
64
Amlodipin 5
mg 1x1 15/06/20 150/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 05/10/20 150/90 Amlodipin 5 mg
Amlodipin 5
mg 1x1 06/11/20 140/90 Amlodipin 5 mg
51 YT
L 69 Amlodipin 5
mg, Furosemid 1x1 (1-0- 0)
24/6/2021 160/100 Amlodipin,
Furosemid 100
03/07/21 160/90 Amlodipin,
Furosemid
52 YT L 71 Amlodipin 5
mg 24/6/2021 140/90 Amlodipin 5 mg 100
Amlodipin 5
mg 1x1 25/8/2021 140/90 Amlodipin 5 mg