NEUROLOGY

Headache Low back pain, Carpal tunnel syndrome, etc

Tension-type headache R/ Na diclofenac 50 mg tab No. X
R/ Paracetamol 500 mg tab No. XVIII S 2 dd tab 1 prn
S 3 dd tab 2 prn atau
atau R/ Meloxicam 15 mg tab No. V
R/ Ibuprofen 400 mg tab No. XVIII S 1 dd tab 1 prn
S 3 dd tab 2 prn
Migraine Ischemic stroke (fase akut) → RUJUK
R/ Sumatriptan 50 mg tab No. X R/ Aspirin 80 mg tab No.IV
S 2 dd tab 1 prn S 1 dd tab 4
Cluster-type headache R/ Clopidogrel 75 mg tab No. IV
R/ Non-rebreathing mask No. I (high-flow oxygen) S 1 dd tab 4
S imm
atau Ischemic stroke (bawa pulang)
R/ Sumatriptan 6 mg/0,5 mL vial I R/ Aspirin 80 mg tab No. VII
S pro inj sc S 1 dd tab 1
R/ Clopidogrel 75 mg tab No. VII
Trigeminal neuralgia S 1 dd tab 1
R/ Carbamazepine 200 mg tab No. XIV +
S 1 dd tab 1 R/ Captopril 12,5 mg tab No. XXI (hypertension)
S 3 dd tab 1
Bell’s palsy R/ Rosuvastatin 20 mg tab No. VII (dyslipidemia)
R/ Prednisone 5 mg tab No. LXXXIV S 1 dd tab 1
S 4 dd tab 3 R/ Metformin 500 mg tab No. XXI (DM)
R/ Artificial tear eye drop fl. I S 3 dd tab 1
S 6 dd gtt 1 OD/OS/ODS
(Tambahan) Hemorrhagic stroke
R/ Acyclovir 400 mg tab No. XXXV R/ Mannitol 20% 100 mL fl. I
S 5 dd tab 1 S pro inf
R/ Infusion set No. I
Benign paroxysmal positional vertigo S imm
R/ Betahistine HCl 8 mg tab No. XV R/ Abocath 18G No. I
S 3 dd tab 1 S imm
atau R/ Nicardipine HCl 25 mg/10 mL vial I
R/ Betahistine mesilate 6 mg tab No. XV S pro inf
S 3 dd tab 1

FOrM25
Tetanus Partial seizure
R/ Metronidazole 500 mg/100 mL vial III R/ Karbamazepin 200 mg tab No. XXVIII
S pro inf S 2 dd tab 1
R/ ATS 50.000 IU amp I Absence seizure (anak 20 kg)
S pro inj im R/ Asam valproate 250 mg/5 mL syr fl. III (15-40mg/kg/hari;
R/ Tetanus toxoid 0,5 mL vial I S 2 dd cth 1 2x sehari)
S pro inj im
R/ Diazepam 5 mg/mL amp II (0,2-0,5 mg/kg;
S pro inf untuk 50 kg)

Bacterial meningitis
R/ Dexamethasone 5 mg/mL amp II (0,15 mg/kg – anak
S pro inf 10 mg – dewasa)
+
Anak < 1 bulan
R/ Ampicillin 1.000 mg vial I (37,5-50 mg/kg/6 jam)
S pro inf
R/ Ceftriaxone 1.000 mg vial I (50 mg/kg/12 jam)
S pro inf
Anak 1 bulan – dewasa 50 tahun
R/ Vancomycin 500 mg vial IV (15-20 mg/kg/12 jam)
S pro inf
R Ceftriaxone 1.000 mg vial IV (2 g/12 jam)
S pro inf
Dewasa > 50 tahun
R/ Vancomycin 500 mg vial IV (15-20 mg/kg/12 jam)
S pro inf
R/ Ampicillin 1.000 mg vial VIII (37,5-50 mg/kg/6 jam)
S pro inf
R/ Ceftriaxone 1.000 mg vial IV (2 g/12 jam)
S pro inf

Generalized seizure
R/ Asam valproate 250 mg tab No. XXVIII
S 2 dd tab 1
Atau
R/ Karbamazepin 200 mg tab No. XXVIII
S 2 dd tab 1

FOrM25
PSYCHIATRY

Antipsychotic Hypersomnia
2st gen. Dopamine receptor antagonist (DRA; atypical) R/ Metilfenidat 10 mg tab no XXI
R/ Risperidone 1 mg tab No. XIV S 3 dd tab 1 ac (30-45 menit)
S 2 dd tab 1
1st gen. DRA (typical) Feeding Disoder
R/ Haloperidol HCl 5mg/mL amp. I R/ Fluoxetine 10 mg cap No. XLII
S pro inj im S 2 dd cap 3

Selective serotonin receptor inhibitors (SSRI)

R/ Fluoxetine 10 mg cap No. XIV
S 1 dd cap 2
atau
R/ Sertraline 50 mg tab No. VII
S 1 dd tab 1

Mood Stabilizer
R/ Lithium 400 mg tab No. XXI
S 3 dd tab 1
atau
R/ Valproic acid 250 mg tab No XIV
S 2 dd tab 1

Insomnia
Early insomnia
R/ Estazolam 2 mg tab No. VII
S 1 dd tab 1 qhs (sebelum tidur)
atau
R/ Zolpidem 10 mg tab No. VII
S 1 dd tab 1 qhs (sebelum tidur)
Middle/Late insomnia
R/ Lorazepam 1 mg tab No. XIV
S 1 dd tab 2 qhs (sebelum tidur)
atau
R/ Zolpidem 10 mg tab No. VII
S 1 dd tab 1 qhs (sebelum tidur)

FOrM25
URO-NEFROLOGY

Urinary Tract Infection (Pielonefritis, sistitis)

R/ Levofloxacin 500 mg tab No. VII
S 1 dd tab 1
atau
R/ Cotrimoxazole forte 960 mg tab No. XXVIII
S 2 dd tab 1
+
R/ Paracetamol 500 mg tab No. XV (demam)
S 3 dd tab 1 prn

Benign prostate hypertrophy

R/ Tamsulosin 0,4 mg tab No. XIV
S 1 dd tab 1

Nephrotic Syndrome
R/ Prednisone 5 mg tab No. LXXXIV
S 4 dd tab 3
R/ Simvastatin 10 mg tab No. XIV
S 1 dd tab 1 noct (malam)
R/ Captopril 12,5 mg tab No. XLII
S 3 dd tab 1
R/ Furosemide 40 mg tab No. VII
S 1 dd tab 1

Nephritic Syndrome
R/ Prednisone 5 mg tab No. LXXXIV
S 4 dd tab 3
R/ Captopril 12,5 mg tab No. XLII
S 3 dd tab 1
R/ Furosemide 40 mg tab No. VII
S 1 dd tab 1
Tambah jika Post-streptococcal
R/ Amoxicillin 250 mg/5 mL syr fl. III (50 mg/kg/hari; q8hr; 10 hari
S 3 dd cth 1 anak 15 kg)

FOrM25
SEXUALLY-TRANSMITTED DISEASE

Urethritis Donovanosis
Gonorrheal R/ Azithromycin 500 mg tab No. II (1x/minggu;
R/ Cefixime 100 mg tab No. IV (single-dose) S 1 dd tab 2 3 minggu)
S 1 dd tab 4
R/ Azithromycin 500 mg tab No. II (single-dose)
S 1 dd tab 2
Non-gonorrheal
R/ Azithromycin 500 mg tab No. II (single-dose)
S 1 dd tab 2
Vaginitis
Bacterial vaginosis, Trichomoniasis
R/Metronidazole 500 mg tab No IV (single-dose)
S 1 dd tab 4
Candidiasis vaginalis
R/ Fluconazole 50 mg cap No. III (single-dose)
S 1 dd cap 3
atau
R/ Itraconazole 100 mg cap No. II (single-dose)
S 1 dd cap 2
atau
R/ Clotrimazole 100 mg tab vaginal No. VI (3 hari; ibu hamil)
S 1 dd tab 2 pro intravagina

Ulkus durum (sifilis)

R/ Penicillin G 2,4 juta IU vial I (single-dose)
S pro inj im

Ulkus mole (chancroid)

R/ Ciprofloxacin 500 mg tab No. VI (3 hari)
S 2 dd tab 1

Limfogranuloma venereum (LGV)

R/ Doxycycline 100 mg cap No. XXVIII (14 hari)
S 2 dd cap 1

FOrM25
OBSTETRIC-GYNECOLOGY

Anemia in pregnancy R/ Metronidazole 500 mg/100 mL vial III (500 mg/8 jam)
R/ Ferro sulfate 300 mg tab No. XLII S pro inf
S 3 dd tab 1
+ Mastitis
R/ Folic acid 0,4 mg tab No. XIV R/ Cloxacillin 500 mg cap No. XL
S 1 dd tab 1 S 4 dd cap 1
atau Atau
R/ Folic acid 1 mg tab No. LVI R/ Erythromycin 250 mg tab No. XL
S 1 dd tab 4 S 4 dd tab 1

Hypertension in pregnancy Premature rupture of membrane (PROM)

R/ Methyldopa 250 mg tab No. XLII (no proteinuria) R/ Ampicillin 1.000 mg vial VIII (2 g/6 jam)
S 3 dd tab 1 S pro inf
atau R/ Gentamicin 80 mg/2 mL vial IV (5mg/kg; untuk 64 kg)
R/ Nifedipine 10 mg tab No. XLII (with proteinuria) S pro inf
S 1 dd tab 3 +
R/ Dexamethasone 5mg/mL amp. V (6 mg/12 jam; 2 hari;
Hiperemesis gravidarum S pro inj im Preterm PROM)
R/ Pyridoxine 10 mg tab No. LVI
S 4 dd tab 1 (1 tab pagi, 1 tab siang, 2 tab malam) Complete Abortus
R/ Dimenhydrinate 50 mg tab No. XV R/ Ferro sulfate 300 mg tab No. XXI
S 3 dd tab 1 S 3 dd tab 1
R/ Mefenamic acid 500 mg tab No. X
Pelvic inflammatory disease S 3 dd tab 1 prn
R/ Cefotetan 2 g vial II (2 g/12 jam)
S pro inf Vulvitis
R/ Doxycycline 100 mg cap No. XXVIII R/ Hydrocortisone 1% krim tube I (3x/hari)
S 2 dd cap 1 S ue
atau R/ Cetirizine 10 mg tab No. X
R/ Ceftriaxone 250 mg vial I (single-dose; ibu hamil) S 2 dd tab 1
S pro inj im

Endometritis
R/ Gentamicin 80 mg/2 mL vial IV (5mg/kg; untuk 64kg)
S pro inf
R/ Ampicillin 1.000 mg vial VIII (2 g/6 jam)
S pro inf
FOrM25
OPHTHALMOLOGY
Bacterial conjunctivitis
R/ Gentamicin 0,3% eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Viral conjunctivitis
R/ Artificial tear eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Allergic conjunctivitis
R/ Dexamethasone eye drop fl. I
S 6 dd gtt 1 ODS
Gonorrheal conjunctivitis
R/ Ceftriaxone 1 g vial fl. I
S pro inj im
R/ Azithromycin 500 mg tab No. II
S 1 dd tab 2
Neonatal conjunctivitis (gonorrheal)
R/ Cefotaxime 500 mg vial I
S pro inj im
Chlamydial conjunctivitis
R/ Tetracyclin 1% eye ointment tube II
S ue
R/ Azithromycin 500 mg tab No. II
S 1 dd tab 2
Bacterial keratitis
R/ Gentamicin 0,3% eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Fungal keratitis
R/ Natamycin 5% eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Viral keratitis
R/ Acyclovir 400 mg tab No. XXXV
S 5 dd tab 1
Atau
R/ Acyclovir 400 mg tab No. LXX
S 5 dd tab 2
Glaucoma → RUJUK
R/ Acetazolamide 250 mg tab No. IV
S 4 dd tab 1
R/ Timolol 0,5% eye drop fl. I
S 2 dd gtt 1 OD/OS/ODS
Hyphema → RUJUK
R/ Acetazolamide 250 mg tab No. IV
S 4 dd tab 1
R/ Dexamethasone eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Blepharitis; Hordeolum – tanpa cuci shampoo bayi
Edukasi:
- cuci sampo bayi
- kompres hangat 3x/hari, @ 10 menit
R/ Gentamicin 0,3% eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
(4x sehari oles 1x) Dakriodenitis
R/ Amoxicillin 500 mg tab No. XXI
S 3 dd tab 1
Dakriosistitis
R/ Gentamicin 0,3% eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Uveitis
R/ Dexamethasone eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
R/ Sulfas atropine 1% eye drop fl. I
(HSV) S 6 dd gtt 1 OD/OS/ODS
Episkleritis
(VZV) R/ Na Diclofenac eye drop fl. I
S 6 dd gtt 1 OD/OS/ODS
Atau dexamethasone eye drop
FOrM25
THT

Otitis ekterna R/ Clotrimazole 1% ear drop fl. I

Sirkumskripta S 3 dd gtt 1 AD/AS/ADS
R/ Polymixin B ear drop fl. I
S 3 dd gtt 1 AD/AS/ADS Herpes zoster otikus, Ramsay-hunt syndrome
R/ Paracetamol 500 mg tab No. XV R/ Acyclovir 400 mg tab No. C
S 3 dd tab 1 S 5 dd tab 2
Diffus, Maligna
R/ Ciprofloxacin 500 mg tab No. XX Acute rhinitis
S 2 dd tab 1 R/ Oxymetazoline 0,05% nasal spray No. I
R/ Paracetamol 500 mg tab No. XV S 2 dd spray 2 NDS
S 3 dd tab 1 R/ Paracetamol 500 mg tab No. XV
S 3 dd tab 1
Otitis media akut Allergic rhinitis
Stadium oklusi; Otitis media efusi R/ Cetirizine 10 mg tab No. X
R/ Oxymetazoline 0,05% nasal spray No. I S 2 dd tab 1
S 2 dd spray 2 ND/NS/NDS R/ Pseudoephedrine HCl 60 mg tab No. XX
Stadium hiperemis, supurasi S 4 dd tab 1
R/ Amoxicillin 500 mg tab No. XXX R/ Mometasone furoate nasal spray No. I
S 3 dd tab 1 S 2 dd spray 1 NDS
R/ Oxymetazoline 0,05% nasal spray No. I Vasomotor rhinitis
S 2 dd spray 2 ND/NS/NDS R/ Pseudoephedrine HCl 60 mg tab No. XX
R/ Paracetamol 500 mg tab No. XV S 4 dd tab 1
S 3 dd tab 1 R/ Mometasone furoate nasal spray No. I
Stadium perforasi S 2 dd spray 1 NDS
R/ H2O2 3% ear drop fl. I Atrophic rhinitis
S 2 dd gtt 2 AD/AS/ADS R/ NaCl 0,9% fl. I
R/ Amoxicillin 500 mg tab No. XXX S pro irigasi NDS
S 3 dd tab 1 R/ Amoxicillin 500 mg tab No. XXX
Otitis media supuratif kronis S 3 dd tab 1
R/ H2O2 3% ear drop fl. I R/ Vitamin A 200.000 IU cap No. III (hari 1, 2, 14)
S 2 dd gtt 2 AD/AS/ADS S 1 dd tab 1
R/ Ofloxacin 0,3% ear drop fl. I Rhinitis medikamentosa
S 2 dd gtt 10 AD/AS/ADS R/ Prednisone 5 mg tab No. LXXXIV
S 4 dd tab 3
Otomikosis
R/ Acetic acid 2% ear drop fl. I
S 2 dd gtt 2 AD/AS/ADS
FOrM25
Sinusitis Epiglotitis
R/ NaCl 0,9% fl. I R/ Ceftriaxone 1.000 mg vial IV (2 g/12 jam)
S pro irigasi NDS S pro inf
R/ Amoxicillin 500 mg tab No. XXX R/ Paracetamol 1g/100ml fl II (500mg q6hr)
S 3 dd tab 1 S pro inf
R/ Paracetamol 500 mg tab No. XV
S 3 dd tab 1
R/ Pseudoephedrine HCl 60 mg tab No. XXVIII
S 4 dd tab 1

Motion sickness
R/ Dimenhydrinate 50 mg tab No. VI
S 3 dd tab 1 prn

Benign paroxysmal positional vertigo

R/ Betahistine HCl 8 mg tab No. XV
S 3 dd tab 1
Atau
R/ Betahistine mesilate 6 mg tab No. XV
S 3 dd tab 1

Bacterial tonsillitis, faringitis, laryngitis

R/ Amoxicillin 500 mg tab No. XXX
S 3 dd tab 1
R/ Paracetamol 500 mg tab No. XV
S 3 dd tab 1

Tonsilitis diphtheria
R/ Erythromycin 500 mg tab No. LVI (anak – 40-50mg/kg/
S 4 dd tab 1 hari; bagi 4)
R/ Anti-diphtheria serum 20.000 IU vial II
S pro inj im
R/ Prednisone 5 mg tab No. LXXXIV (bullneck)
S 4 dd tab 3
Nb. ADS 20.000 IU (hidung)
ADS 40.000 IU (tonsil/faring/laring)
ADS 80.000 IU (kombinasi)
ADS 80.000 – 100.000 IU (+ penyulit, bullneck, telat
berobat >72 jam)
FOrM25
GASTROENTEROLOGY

Dyspepsia R/ Clarithromycin 500 mg tab No. XIV

Epigastric Pain Syndrome S 2 dd tab 1
R/ Omeprazole 20 mg cap No. XIV R/ Amoxicillin 500 mg tab No. XXVIII
S 2 dd cap 1 ac S 2 dd tab 2
Post Prandial Distress Syndrome
R/ metoklopramid 10 mg tab No. XV
S 3 dd tab 1 ac Demam tifoid
R/ Chloramphenicol 500 mg cap No. XL
S 4 dd cap 1
Anti-emetik Atau
R/ Domperidone 10 mg tab No. XV R/ Chloramphenicol 125 mg/5 mL syr fl. VII (25mg/kg/6 jam;
S 3 dd tab 1 ac S 4 dd cth 2 anak; 10 kg)
Atau
Disentri amoeba R/ Chloramphenicol 125 mg/5 mL syr fl. XIV (anak; 20 kg)
R/ Metronidazole 500 mg tab No. XXI S 4 dd cth 4
S 3 dd tab 1 Atau
R/ Oralit sachet No. X R/ Amoxicillin 500 mg tab No. XXX (ibu hamil)
S prn S 3 dd tab 1
+ +
R/ Zinc 20 mg tab dispersible No. X (usia > 6 bulan) R/ Paracetamol 500 mg tab No. XV
S 1 dd tab 1 S 3 dd tab 1
Atau
R/ Zinc 20 mg tab dispersible No. V (usia < 6 bulan) IBS-C (Constipation)
S 1 dd tab ½ R/ Laktulosa syr 3.335 g/5 ml Fl. I
S 1 dd cth 3
Disentri basiler
R/ Ciprofloxacin 500 mg tab No. VI IBS-D (Diarrhea)
S 2 dd tab 1 R/ Loperamid 2 mg tab No. X
Atau S 1 dd tab 1 (2 tab initially, then 1 tab after
R/ Azithromycin 500 mg tab No. II (single dose; ibu hamil) each diarrhea)
S 1 dd tab 2
+
Obat diare (cairan, tablet zinc)

Ulkus peptikum e.c. H. pylori

R/ Omeprazole 20 mg cap No. XIV
S 2 dd cap 1
FOrM25
CARDIOLOGY
Acute Heart Failure (wet cold)
Hypertension <90mmHg tanpa tanda syok
R/ Captopril 12,5 mg tab No. XLII Dobutamin 2 mcg/kg/menit IV drips
S 3 dd tab 1 <90mmHg dengan tanda syok (HR <50x/menit)
Atau Dopamin 5-20 mcg/kg/menit IV drips
R/ Valsartan 80 mg tab No. XIV <90mmHg dengan tanda syok (HR >50x/menit)
S 1 dd tab 1 Norepinefrin 0,1-0,5 mcg/kg/menit IV drips
Atau
R/ Bisoprolol 2,5 mg tab No. XIV Acute Coronary Syndrome
S 1 dd tab 1 R/ Nasal canule No. I
Atau S imm
R/ Amlodipin 5 mg tab No. XIV R/ ISDN 5 mg tab No. III
S 1 dd tab 1 S imm pro sublingual
R/ Aspirin 80 mg tab No.IV
Congestive Heart Failure S 1 dd tab 4
R/ Captopril 12,5 mg tab No. XLII R/ Clopidogrel 75 mg tab No. IV
S 3 dd tab 1 S 1 dd tab 4
Bila perlu + Bila perlu +
R/ Bisoprolol 2,5 mg tab No. XIV R/ Morfin sulfat 10mg/ml amp I (4-8 mg IV initially)
S 1 dd tab 1 S pro infus
Bila perlu +
R/ Spironolactone 25 mg tab No. XIV Stable angina pectoris
S 1 dd tab 1 R/ Aspirin 80 mg tab No. VII
+ S 1 dd tab 1
R/ Furosemide 40 mg tab No. VII (edema) R/ Rosuvastatin 20 mg tab No. VII
S 1 dd tab 1 S 1 dd tab 1
R/ ISDN 5mg tab No. X
Acute Heart Failure (dry warm) S prn pro sublingual
Adjust oral therapy
Acute Heart Failure (dry cold) SVT, Atrial Flutter
Fluid challenge R/ Bisoprolol 2,5 mg tab No. XIV
Acute Heart Failure (wet warm) S 1 dd tab 1
R/ Furosemide 10 mg/ml amp 4
S pro infus Atrial Fibrillation
R/ Captopril 12,5 mg tab No. XLII R/ Bisoprolol 2,5 mg tab No. XIV
S 3 dd tab S 1 dd tab 1
R/ Warfarin 2 mg tab No. XIV
S 1 dd tab 1
FOrM25
RESPIRATORY SYSTEM

Tuberculosis - (untuk 50 kg) PPOK eksaserbasi

R/ Rifampisin 450 mg tab No. XIV (10 mg/kg) R/ Salbutamol 2,5 mg amp. III
S 1 dd tab 1 ac S imm pro nebulisasi
R/ Isoniazid 300 mg tab No. XIV (5 mg/kg) R/ Prednisone 5 mg tab No. XL (40mg/hari selama 5 hari)
S 1 dd tab 1 ac S 4 dd tab 2
R/ Pyrazinamide 500 mg tab No. XLII (25 mg/kg) R/ Co-amoxiclav 625 mg tab No. XXX
S 1 dd tab 3 ac S 3 dd tab 1
R/ Ethambutol 250 mg tab No. XLII (15 mg/kg)
S 1 dd tab 3 ac Asma
Controller
Pneumonia R/ Budesonide 200 mcg inhalasi No. I
Rawat jalan S 3 dd puff 1 (dosis rendah)
R/ Co-amoxiclav 625 mg tab No. XXI Atau
S 3 dd tab 1 R/ Budesonide 200 mcg inhalasi No. I
R/ Paracetamol 500 mg tab No. XV S 3 dd puff 2 (dosis sedang)
S 3 dd tab 1 +
R/ Ambroxol HCl 30 mg tab No. XXI Reliever
S 3 dd tab 1 R/ Salbutamol 100 mcg inhalasi No. I
Pneumonia Anak S 3 dd puff 2 prn
R/ Amoxicillin 250 mg/5 mL syr fl. II (40 mg/kg/12 jam; 5 hari
S 2 dd cth 2 anak 12.5 kg) Flu Burung
Atau R/ Oseltamivir 75 mg cap No. X
R/ Amoxicillin 250 mg/5 mL syr fl. IV (anak 25 kg) S 2 dd cap 1
S 2 dd cth 4
+ Influenza
R/ Paracetamol 125 mg/5 mL syr fl. II (10-15 mg/kg/8 jam; R/ Pseudoefedrin HCl 60 mg tab No. XX
S 3 dd cth 1 anak 10 kg) S 4 dd tab 1
Atau R/ Paracetamol 500 mg tab No. XIV
R/ Paracetamol 125 mg/5 mL syr fl. III (anak 20 kg) S 3 dd tab 1
S 3 dd cth 2
Pertussis
Asma eksaserbasi R/ Erythromycin 200 mg/5 mL syr fl. IV (10-12.5 mg/kg/6 jam;
R/ Salbutamol 2,5 mg amp. III S 4 dd cth 1 anak 20kg)
S imm pro nebulisasi +
R/ Prednisone 5 mg tab No. XL (40mg/hari selama 5 hari) Paracetamol syr
S 4 dd tab 2

FOrM25
METABOLIC SYSTEM

Diabetes Mellitus Hypothyroid

R/ Metformin 500 mg tab No. XLII R/ Levothyroxine 100 mcg tab No. XIV
S 3 dd tab 1 S 1 dd tab 1
Atau/+
R/ Glibenclamide 2,5 mg tab No. XIV Anemia defisiensi besi
S 1 dd tab 1 R/ Ferro sulfate 300 mg tab No. XLII
Atau/+ S 3 dd tab 1
R/ Pioglitazone 15 mg tab No. XIV Anemia megaloblastik ec. Defisiensi B9 (asam folat)
S 1 dd tab 1 R/ Folic acid 1 mg tab No. XIV
S 1 dd tab 1
Hypertension Anemia megaloblastik ec. Defisiensi B12 (sianokobalamin)
R/ Captopril 12,5 mg tab No. XLII R/ Cyanocobalamin 500 mcg/mL amp. II (ulangi selama 7 hari)
S 3 dd tab 1 S pro inj im
Atau
R/ Valsartan 80 mg tab No. XIV Gout arthritis
S 1 dd tab 1 Fase akut
Atau R/ Na diclofenac 50 mg tab No. XXI
R/ Bisoprolol 2,5 mg tab No. XIV S 3 dd tab 1
S 1 dd tab 1 R/ Colchicine 0,5 mg tab No. XLII (pertama – 2 tab; diikuti
Atau S 3 dd tab 2 1 tab/jam hingga nyeri hilang)
R/ Amlodipin 5 mg tab No. XIV Fase interkritikal (tenang)
S 1 dd tab 1 R/ Allopurinol 100 mg tab No. XIV
S 1 dd tab 1
Dyslipidemia
R/ Simvastatin 10 mg tab No. XIV Osteo arthritis, rheumatoid arthritis
S 1 dd tab 1 noct (malam) R/ Na diclofenac 50 mg tab No. XXI
Atau S 3 dd tab 1 prn
R/ Fenofibrate 100 mg cap No. XIV Atau
S 1 dd cap 1 R/ Ibuprofen 400 mg tab No. XXVIII
S 4 dd tab 1 prn
Hyperthyroid Atau
R/ methimazole 10 mg tab No. XXVIII R/ Meloxicam 7,5 mg tab No. VII
S 2 dd tab 1 S 1 dd tab 1
R/ Propanolol 10 mg tab No. XLII
S 3 dd tab 1 Osteoporosis
R/ Alendronate 70 mg tab No. II
S 1 dd tab 1 (70 mg per minggu)
FOrM25
TROPICAL DISEASES

Demam Cacing-cacing
R/ Paracetamol 500 mg tab No. XIV R/ Albendazole 400 mg tab No. I (single-dose)
S 3 dd tab 1 S 1 dd tab 1
Atau Atau
R/ Paracetamol 125 mg/5 mL syr fl. II (10-15 mg/kg/8 jam; R/ Albendazole 400 mg tab No. III (3 hari; Strongyloides sp.)
S 3 dd cth 1 anak 10 kg) S 1 dd tab 1
Atau
R/ Paracetamol 125 mg/5 mL syr fl. III (anak 20 kg) Taeniasis
S 3 dd cth 2 R/ Praziquantel 600 mg tab No. I (single-dose)
S 1 dd tab 1
Dengue fever, Dengue hemorrhagic fever Schistosomiasis – (untuk 50 kg)
R/ Paracetamol 500 mg tab No. XIV R/ Praziquantel 600 mg tab No. VI (60 mg/kg/hari;
S 3 dd tab 1 S 3 dd tab 2 S. japonicum)
Atau
Leptospirosis R/ Praziquantel 600 mg tab No. IV (40 mg/kg/hari;
R/ Doxycycline 100 mg cap No. XIV S 2 dd tab 2 S. mansonii;
S 2 dd cap 1 S. haematobium)

Thyphoid fever Malaria – (untuk 50 kg)

R/ Chloramphenicol 500 mg cap No. XL R/ DHP 40 mg/320 mg tab No. IX (Ibu hamil & P. malariae
S 4 dd cap 1 S 1 dd tab 3 – hanya DHP 3 hari)
Atau +
R/ Chloramphenicol 125 mg/5 mL syr fl. VII (25 mg/kg/6 jam; R/ Primaquin 15 mg tab No. I (P. falciparum)
S 4 dd cth 2 anak 10 kg) S 1 dd tab 1
Atau Atau
R/ Chloramphenicol 125 mg/5 mL syr fl. XIV (anak 20 kg) R/ Primaquin 15 mg tab No. XIV (P. vivax, P. ovale)
S 4 dd cth 4 S 1 dd tab 1
Atau
R/ Amoxicillin 500 mg tab No. XXX (ibu hamil) HIV
S 3 dd tab 1 R/ Antiretroviral KDT tab No. XIV
S 1 dd tab 1
Filariasis – (untuk 50 kg)
R/ Diethylcarbamazine 100 mg tab No. XXXVI (2mg/kg/8jam) KDT terdiri dari
S 3 dd tab 1 - Tenofovir 300 mg / Zidovudine 300 mg
- Lamivudine 150 mg
- Efavirenz 600 mg

FOrM25
DERMATOLOGY

Gatal Tinea unguium

R/ Cetirizine 10 mg tab No. XIV Sistemik
S 2 dd tab 1 R/ Terbinafin 250 mg tab No. XIV (6 minggu – tangan;
S 1 dd tab 1 12 minggu – kaki)
Tinea Kapitis
Topikal Pytiriasis versicolor
R/ Selenium sulfide 2,5% fl. II (1x/2 hari) Topikal
S ue R/ Selenium sulfide 2,5% fl. I (1x/hari; 15 menit; 3hari;
+ S ue ulangi minggu depan)
Sistemik Atau
Gray patch (Microsporum sp.) R/ Mikonazol 2% krim tube II (2x/hari; wajah)
R/ Griseofulvin 500 mg tab No. XIV (8 minggu) S ue
S 1 dd tab 1 Bila perlu +
Atau Sistemik - (Lesi kronis, luas, gagal topikal)
Black dot (Tricophyton sp.) R/ Ketokonazol 200 mg tab No. X
R/ Terbinafin 250 mg tab No. XIV (2-4 minggu; S 1 dd tab 1
S 1 dd tab 1 > 40 kg)
Atau Kandidiasis kutis
R/ Terbinafin 250 mg tab No. VII (20-40 kg) Topikal
S 1 dd tab ½ R/ Mikonazol 2% krim tube II (2x/hari; 2 minggu)
Tinea korporis, tinea cruris S ue
Topikal Bila perlu +
R/ Terbinafin 1% krim tube II (1x/hari; Sistemik
S ue 1-2 minggu) R/ Flukonazol 50 mg cap No. XIV
Bila perlu + S 1 dd cap 1
Sistemik - (lesi kronis, luas) Kandidiasis oral
R/ Terbinafin 250 mg tab No. XIV (2 minggu) Topikal
S 1 dd tab 1 R/ Nistatin 100.000 IU drop fl. I (1-2 minggu)
Tinea pedis, manus S 4 dd gtt 4
Topikal Bila perlu +
R/ Terbinafin 1% krim tube II (1x/hari; Sistemik – (lesi ≥ 50% mukosa, deep erosive lesions)
S ue 1-2 minggu) R/ Flukonazol 50 mg cap No. XIV (1-2 minggu)
+ S 1 dd cap 1
Sistemik
R/ Terbinafin 250 mg tab No. XIV (2 minggu) Herpes simpleks
S 1 dd tab 1 R/ Acyclovir 200 mg tab No. XXXV
S 5 dd tab 1
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Varicella, Herpes zoster Multibasilar
R/ Acyclovir 400 mg tab No LXX R/ Rifampicin 600 mg tab No. I (hari 1/bulan;
S 5 dd tab 2 S 1 dd tab 1 12 bulan)
Post-herpetic neuralgia R/ Dapson 100 mg tab No. XXVIII (12 bulan)
R/ Amitriptyline 25 mg tab No. VII S 1 dd tab 1
S1 dd tab 1 noct (malam) R/ Clofazimine 100 mg cap No. III (hari 1/bulan;
S 1 dd tab 3 12 bulan)
Hydradenitis suppurativa R/ Clofazimine 50 mg cap No. XXVII (hari 2-28
R/ Clindamycin 300 mg cap No. XXVIII (10 minggu) S 1 dd tab 1 12 bulan)
S 2 dd cap 1
R/ Rifampicin 300 mg cap No. XXVIII (10 minggu) Scabies
S 2 dd cap 1 R/ Permethrin 5% krim tube II (1x/minggu; 8 jam;
S ue noct (malam) ulangi minggu depan)
Erythrasma
R/ Erythromycin 250 mg tab No. XXVIII Pediculosis
S 4 dd tab 1 R/ Permethrin 1% lotion tube I (1x/minggu; 10 menit;
S ue setelah keramas saat
Pioderma rambut basah; ulangi
Topikal minggu depan)
Lesi basah
R/ Permanganas kalikus fl. I Cutaneous larva migrans
S pro kompres R/ Albendazole 400 mg tab No. III
Lesi kering S 1 dd tab 1
R/ Mupirocin 2% krim tube II (3x/hari; 1 minggu)
S ue Dermatitis kontak, neurodermatitis, dermatitis numularis
Bila perlu + R/ Mometasone furoate 0,1% krim tube I (1X/hari)
Sistemik S ue
R/ Co-amoxiclav 625 mg tab No. XXX R/ Lanolin 10% krim tube I
S 3 dd tab 1 S ue prn

Lepra Pytiriasis rosea

Pausibasilar R/ Cetirizine 10 mg tab No. X
R/ Rifampicin 600 mg tab No. I (hari 1/bulan; S 2 dd tab 1
S 1 dd tab 1 6 bulan) Pytiriasis alba
R/ Dapson 100 mg tab No. XXVIII (6 bulan) R/ Hydrocortisone 1% krim tube I (3x/hari)
S 1 dd tab 1 S ue
R/ Lanolin 10% krim tube I
S ue prn

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Akne vulgaris
Ringan
R/ Asam retinoat 0,05% krim tube I (1x/hari)
S ue noct (malam)
R/ Tabir surya SPF 30 tube I (pagi; 30 menit sebelum
S ue beraktivitas keluar)
Sedang
Obat derajat ringan
+
R/ Benzoil peroksida 5% krim tube I (pagi)
S ue
R/ Doksisiklin 100 mg cap No. XIV
S 1 dd cap 1

Psoriasis
R/ Klobetasol propionate 0,05% krim tube I (2x/hari)
S ue

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