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Morbilli
Preceptor:
Patient Identity
Name
: L.A
: 10 years 3 months
Gender : Male
Address : KP TANGSI 3/6 CIKARANG. East Jakarta
Nationality : Indonesia
Religion : Moslem
Date of admission
Parent Identity
Father
Mother
Name
Mr. S
Mrs. M
Age
40 years old
37 years old
Job
Employee
Housewife
Nationality
Indonesia
Indonesia
Religion
Islam
Islam
Education
High School
High School
History Taking
The
Chief complain
Additional complains :
History of Present
Illness
A 10 years old boy came to Raden
Said Sukanto Police Center Hospital
suffering from fever since four days
before admission to the hospital. This
complains also followed by rash all
over his body, cough, flu, headache,
nausea, vomiting, diarrhea, abdominal pain
since 4 days and swallowing pain since 1 day
before admission.
History of Present
Illness
Since 4 days
before
admission the
patient had
fever, rash all
over his body
4 days before
admission the patient
had cough, flu,
headache, nausea,
vomiting, abdominal
pain, diarrhea 3 times a
day
1 day before
admission the
patient had
swallowing pain
Bacillary
Dysentry
Bronchitis
Amoeba
Dysentry
Pneumonia
Diarrhea
Morbilli
Thypoid
Pertussis
Worms
Varicella
Surgery
Diphteria
Brain
Concussion
Malaria
Fracture
Polio
Drug Reaction
Enteritis
Prenatal History
Antenatal Care
Antenatal check ups performed at the local
clinic by a doctor since she knew shes
pregnant and every months until she gave
birth. There was no problems during
pregnancy.
Birth History
Labor
: Clinic
: 38 weeks
: 3400 grams
Body length
: 50 cm
Development History
First dentition: 6 months old
Psychomotor development
Smile
Slant
: 1 month old
: 2 months old
Speech Initation
Prone Position
: 2 months old
: 4 months old
Sitting
Crawling
: 6 months old
Standing
Walking
: 10 months old
: 8 months old
: 12 months old
History ofImmunization
Eating
History
Immunization Frequen
Time
Breast milk: 6 months
cy
Formula milk: SGM since t months old
0,1,6
Baby biscuit: Biscuit Milna and RegalHepatitis B 3 times
months old
Fruit and vegetables: Banana, papaya
Polio
4 times
BCG
1 time
DPT
0,2,4,6
months old
1 month
old
3 times
2,4,6
months old
Hib
3 times
2,4,6
months old
Measles
1 time
9 months
old
Family History
There are not any significant illnesses or
chronic illnesses based on the parent
declared.
History of Disease in Other Family Members / Around the
House
Physical Examination
Date : August 25th 2015
General Status
General condition: Mildly ill
Consciousness
: Compos Mentis
Pulse : 100x /min, regular, full, strong.
Breathing rate
: 20x /min
Temperature : 38.3oC (per axilla)
Anthropometry Status
Weight : 26 kilogram
Height
: 131 cm
Antropometry
Status
Weight : 26 kg
Height : 131 cm
Nutritional status based
NCHS 2000
(National Center for Health
Statistic) year 2000
WFA (Weight for Age)
26/31 x 100% = 83 %
HFA (Height for Age)
131/137 x100% = 95 %
WFH (Weight for Age)
26/26 x 100% = 100 %
Conclusion:
The
nutritional status.
patient
has
good
Neck
Lymph node enlargement (+), scrofuloderma (-), rash (+)
of
tympanic
not
Neurological
Examination
Meningeal sign
Nuchal rigidity
Kernig sign
Lasegue sign
Brudzinski 1
Brudinski 2
Motoric Examination
Power
Hand
5 5 5 5/ 5 5 5 5
Feet
5 5 5 5/ 5 5 5 5
Tonus
Hand
Normotonus / Normotonus
Feet
Normotonus / Normotonus
Trophy
Hand
Normotrophy / Normotrophy
Feet
Normotrophy / Normotrophy
Biceps
+/+
Triceps
+/+
Lower extrimities
Patella
+/+
Achilles
+/+
Clonus
Hoffman
-/-
Trommer
-/-
Patella
-/-
Achilles
-/-
Lower extrimities
Babinsky
-/-
Chaddock
-/-
Oppenheim
-/-
Gordon
-/-
Schaeffer
-/-
Autonom
Examination
Defecation Normal ( 1-2 times daily)
Urination
Sweating
Normal
Laboratory Investigation
Hematolgy
Result
Normal Value
Haemoglobin
12.8 g/dL
13-16 g/dL
Leukocytes
4.900/uL
5,000 10,000/L
Hematocrits
35 %
40 48 %
Trombocytes
274.000/ uL
150,000 400,000/L
Erythrocytes
4.68 million/uL
4 5 million/L
Working Diagnosis
Morbilli
Dd/ Rubella
Management
IVFD RL 1650cc 22dpm
Inj. Cefotaxime 2 x 1 g i.v.
Ambroxol 3 x 1 c
Sanmol 3 x 1 c
Lacto B 2 x 1 sach
Zinkid 1 x 1 c
Domperidone 2 x 1 c
Vit A 1x200.000 units
Prognosis
Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad
bonam
Cough (+)
Rash (+)
Coryza (+)
Fever (+)
Morbilli
Cough (+)
Rash (+)
Coryza (+)
S : Chest pain when breathing still persist but the pain is reduced,
Fever (-)
shortness of breath (-), subfebrile fever (-), dizziness (-) and cough is
reduced.
A
P
Morbilli
IVFD RL 1650cc 22dpm
Cefotaxime 2 x 1 g i.v.
: Patient can Inj.
go home.
Ambroxol 3 x 1 cth
Patient is asked to check Mantoux test, then bring the result to the
polyclinic.Sanmol 3 x 1 cth
Lacto B 2 x 1 sach
Zinkid 1 x 1 cth
Domperidone 2 x 1 cth
Vit A 1x200.000 units
Salicyl talc
Cough (+)
Rash (+)
Fever (-)
S : Chest pain when breathing still persist but the pain is reduced,
shortness of breath (-), subfebrile fever (-), dizziness (-) and cough is
reduced.
A
P
Morbilli
IVFD
1650cc 22dpm
: Suspect lung
TB dd/RL
bronchopneumoni
Inj. Cefotaxime 2 x 1 g i.v.
Ambroxol 3 x 1 cth
: Patient can go home.
Sanmol 3 x 1 cth
Patient is Lacto
asked toB
check
2 x Mantoux
1 sach test, then bring the result to the
polyclinic.
Zinkid 1 x 1 cth
Domperidone 2 x 1 cth
Vit A 1x200.000 units
Salicyl talc
Literature Review
Definition
Measles is an acute childhood infectious disease
caused by a virus. The virus is transmitted from
person to person through coughing or sneezing.
The disease is characterized by:
Etiology
Measles virus is a single-stranded, lipid-enveloped
RNA virus in the family Paramyxoviridae and
genus Morbillivirus.
Of the 6 major structural proteins of measles virus,
the 2 most important in terms of induction of
immunity are the hemagglutinin (H) protein and
the fusion (F) protein.
The neutralizing antibodies are directed against
the H protein, and antibodies to the F protein limit
proliferation of the virus during infection.
Pathogenesis and
Pathology
The portal of entry of measles virus is through the respiratory
tract or conjunctivae following contact with large droplets or
small-droplet aerosols in which the virus is suspended.
Diagnosis
The diagnosis of measles is almost always based on
clinical and epidemiologic findings. Laboratory findings
in the acute phase include reduction in the total white
blood cell count, with lymphocytes decreased more
than neutrophils. Absolute neutropenia has been
known to occur, however.
Serologic confirmation is most conveniently made by
identification of immunoglobulin M (IgM) antibody in
serum. Serologic confirmation may also be made by
demonstration of a fourfold rise in IgG antibodies in
acute and convalescent specimens collected 2-4
weeks later.
Supporting
Examination
Chest radiography
If bacterial pneumonia is suspected, perform chest
radiography. The frequent occurrence of measles
pneumonia, even in uncomplicated cases, limits the
predictive value of chest radiography for bacterial
bronchopneumonia.
Lumbar puncture
If encephalitis is suspected, perform a lumbar puncture.
CSF examination reveals the following:
Increased protein
Normal glucose
Mild pleocytosis with a predominance of lymphocytes
Management
Management of measles is supportive. Maintenance of hydration,
oxygenation, and comfort are goals of therapy. Antipyretics for
comfort and fever control are useful.
Antiviral therapy is not effective in the treatment of measles in
otherwise normal patients.
For patients with respiratory tract involvement, airway humidification and supplemental oxygen may be of benefit. Respiratory
failure due to croup or pneumonia may require ventilatory support.
Oral rehydration is effective in most cases, but severe dehydration
may require intravenous therapy.
Vitamin A deficiency in children in developing countries has long
been known to be associated with increased mortality from a variety
of infectious diseases, including measles. The American Academy of
Pediatrics suggests vitamin A therapy for selected patients with
measles
Prevention
Complication
Morbidity and mortality from measles are
greatest in patients 5 years of age
(especially 1 years of age) and 20 years
of age