LAPORAN KASUS

MORBILI + GIZI KURANG POST MARASMUS + POST-COLOSTOMY EC

INVAGINASI
PEMBIMBING:
dr. Pertin Sianturi, M.Ked (Ped), Sp.A(K)

PENYUSUN :
Handayani

(100100337)

KEPANITERAAN KLINIK RSUP H. ADAM MALIK

DEPARTEMEN ILMU KESEHATAN ANAK
FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA
MEDAN
2015
CHAPTER 3
CASE REPORT

Pediatric Department
Medical Study University of North Sumatra
Medical Record
No : 00.61.79.80
Name: Doli Arun P. S.
Job : -

Date :
Age : 11 month
Add : Desa Sosor Tolong Sihite

Day :
Sex : Male
Religion :
Islam

Tlp: -

III
Hp: -

Main complain : Fever

Additional Complain : Cough, Makulopapular rash all over the skin, Vomit
History :

Fever with rash has happen since 2 days ago (4 April 2015) with temperature 38,9 oC.
Fever was followed by the appearing of maculopapular rash on neck and face. Koplik

spot was not found on 4 April 2015.

Cough has happen since 2 days ago. Unproductive cough (+), odor (-), hemoptoe (-),

history of hemoptoe (-)

Coryza (-) ; Conjunctivitis (-)
History of measles immunization (-)
History of colostomy (+) since 29 September2014 from a surgeon based on clinical
findings and radiologist. Patient was previously treated in a hospital due to pain and

mass in abdomen and was diagnosed with intussusception.

History of nutrition :
o Exclusive breast milk : 0-6 month
o Susu formula
: 0-6 month
o Nasi Tim
: 6-11 month
Seizure (-) ; Hypertension (-) ; Diabetes (-)

Status Presens:
KU: Sedang

Sianosis: (-)

Consciousness : Compos Mentis

Ortopnu: (-)

BP: 120/70 mmHg

Dispnoe (-)

HR: 123 x/i

Ikterus (-)

RR: 25 x/i

Suhu: 38,3 oC (6 April 2015 pukul

14:15)

Edema (-)
Pale (-)

Gizi buruk BB/U

PB/U
BB/TB

= z-score < -3
= z-score < -3
= z-score < -3

Pemeriksaan Fisik:
Head : normosephal (LK = 40 cm)

Face

: simetris left = right, makulopapular rash on face

Hair

: hitam, lurus, sulit dicabut

Fontanela anterior : menutup

Ear

Eyes
: cekung (-), dry (-), conjungtivitis (-), pupil isokor(+/+), refleks
cahaya (+/+), conjungtiva palpebrae inferior pucat (-/-), icteric (-)

Nose

: rhinorhea (-), pernapasan cuping hidung (-)

Lips

: kering (-), stomatitis (-)

Tongue: candidiasis oral (-), tremor (-),

Throat

: hiperemis (-)

Tonsil

: hiperemis (-)

: otorrhea (-)

Neck : TVJ : R - 2 cmH2O, pembesaran KGB (-), kaku kuduk (-)

Thorax :

Inspection
Palpation
Percussion
Auscultation

: Symmetric Left = Right

: Sten Phremitus Left = Right
: Sonor Left = Right
: Breathing sound : vesicular
Additional sound : (-)

Heart : ictus cordis tidak tampak

Left border
: linea midclavicularis
Right border
: linea parasternalis kanan
Upper border
: ICS 2-3
Lower border
: ICS 5-6
Abdomen : datar, ikut gerak napas, massa tumor (-), nyeri tekan (-), soepel, timpani (+),
pekak hepar (+), asites (-), peristaltik (+) N ; Liver, spleen, renal : unpalpable ; 2 stomas on
the abdomen : right iliaca region and left lumbar region.
Extremity : pulse 124 x/i ; reguler ; t/v cukup ; akral hangat ; CRT<3 ; cyanoses(-) ; clubbing
finger(-)
Genitalia : Normal
Laboratorium findings : 31 March 2015

Haematology
CBC

Haemoglobin (Hb)

: 12.8 g%

(11.1-14.4)

Erythrocyte (RBC)

: 4.41 x 106/mm3

(3.71-4.25)

Leukocyte (WBC)

: 5.83 x 103/mm3

(6.0-17.5)

Hematocrit

: 38.9 %

(35-41)

Thrombocyte (PLT)

: 309 x 103/mm3

(219-497)

MCV

: 88.20 fL

(82-100)

MCH

: 29.00 pg

(24-30)

MCHC

: 32.9 g %

(28-32)

RDW

: 15.00 %

(14.9-18.7)

MPV

: 9.5 fL

(7.2-10.0)

PCT

: 0.29 %

Thrombocyte (PLT)

: 309 x 103/mm3

PDW

: 10.5 fL

(219-497)

Hitung Jenis :
-

Neutrophil

: 56.7 %

(37-80)

Lymphocyte

: 22.3 %

(20-40)

Monocyte

: 20.1 %

(2-8)

Eosinophil

: 0,70 %

(1-6)

Basophil

: 0,200 %

(0-1)

Neutrophil absolute : 3.31 x 103/L

(1.9-5.4)

Lymphocyte absolute: 1.30 x 103/L

(3.7-10.7)

Monocyte absolute: 1.17 x 103/L

(0.3-0.8)

Eosinophil absolute: 0.04 x 103/L

(0.20-0.50)

Basophil absolute : 0.01 x 103/L

(0-0.1)

Hepar
Albumin

:3.6 g/dL

(3.8-5.4)

Sodium (Na)

: 133 mEq/dL

(135- 155)

Calcium (Ca)

:9.7 mg/dL

(8.4 -10.8)

Clorida (Cl)

:106 mEq/dL

(96 106)

Kalium (K)

:3.6 mEq/dL

(3.6 5.5)

Electrolyte

Imunnoserology
Autoimune CRP qualitative: positive
Procalcitonin

:4.15 ng/dL

(<0.05)

Conclusion : Morphology of eritrosit, leukosit, and thrombocyte is normal. High risk of

septic shock (procalcitonin)
Masukkan foto kurva WHO pasien
Differential Diagnose :
???
Diagnose :
Morbili + Gizi Kurang post Marasmus + Post-colostomy ec Invaginasi
Treatment in ward :

inj. Parasetamol 90 mg/6 jam/ IV ok saat minum obat dimuntahkan

F 100 cc / 3 jam dengan 2,2 cc min max
Diet bubur milna penambah BB 2x sehari
As folat 1x1 mg
Multivitamin dengan Fe 1x0,5 cc
Gentamicin salep 2x1 applic

Planning :

Rawat Isolasi
Consult to infection division

FOLLOW UP
4th April 2015 (21:00)
S
O

A
P

: mencret (-); muntah (-)

: sensorium : CM
Temp : 37,8 oC
BB : 6 kg
Kepala
: mata R/C (+/+) ; pupil isokor (+/+); conj. palp inferior pucat (-/-)
T/H/M
: dalam batas normal
Dada
: SF; retraksi (-) ; HR : 108 x/i ; reguler ; desah (-)
RR : 23 x/i ; reguler ; ronkhi (-/-)
Perut
: Soepel, peristaltik (+) N; H/L : tidak teraba
Ekstremitas : HR : 108x/i ; reguler ; t/v cukup ; akral hangat
: marasmus + post colostomy ec invaginasi
: F 100 cc / 3 jam dengan 2,2 cc min max
Diet bubur milna penambah BB 2x sehari
As folat 1x1 mg
Multivitamin dengan Fe 1x0,5 cc
Gentamicin salep 2x1 applic

5th April 2015 (06:00)

S
O

A
P

: demam (+) ; bercak kemerahan seluruh tubuh (+); batuk (+)

: sensorium : CM
Temp : 38,9 oC
BB : 6 kg
Kepala
: mata R/C (+/+) ; pupil isokor (+/+); conj. palp inferior pucat (-/-)
T/H/M
: dalam batas normal
Dada
: SF; retraksi (-) ; HR : 120 x/i ; reguler ; desah (-)
RR : 36 x/i ; reguler ; ronkhi (-/-)
Perut
: Soepel, peristaltik (+) N; H/L : tidak teraba
Ekstremitas : HR : 120x/i ; reguler ; t/v cukup ; akral hangat
: morbili + marasmus + post colostomy ec invaginasi
: Inj. Parasetamol 90 mg/ 6 jam/ IV ok saat minum obat dimuntahkan
Rawat isolasi
F 100 cc / 3 jam dengan 2,2 cc min max
Diet bubur milna penambah BB 2x sehari
As folat 1x1 mg
Multivitamin dengan Fe 1x0,5 cc
Gentamicin salep 2x1 applic

6th April 2015 (06:00)

S
O

: demam (+) ; bercak kemerahan seluruh tubuh (+); batuk (+) ; muntah (+) 5 kali ; diet
habis (+)
: sensorium : CM
Temp : 38,3 oC
BB : 6 kg
Kepala
: mata R/C (+/+) ; pupil isokor (+/+); conj. palp inferior pucat (-/-)
T/H/M
: dalam batas normal
Dada
: SF; retraksi (-) ; HR : 136 x/i ; reguler ; desah (-)
RR : 40 x/i ; reguler ; ronkhi (-/-)
Perut
: Soepel, peristaltik (+) N; H/L : tidak teraba
Ekstremitas : HR : 136x/i ; reguler ; t/v cukup ; akral hangat

A
P

: morbili + gizi kurang post marasmus + post colostomy ec invaginasi

: Inj. Parasetamol 90 mg/ 6 jam/ IV ok saat minum obat dimuntahkan
Rawat isolasi
F 100 cc / 3 jam dengan 2,2 cc min max
Diet bubur milna penambah BB 2x sehari
As folat 1x1 mg
Multivitamin dengan Fe 1x0,5 cc
Gentamicin salep 2x1 applic