Case Report of Morbili with

Secondary Bronchopneumonia
Infections without
Immunization History

Supervisor : Dr. Dini Lailani, Sp.A

Arranged by: Rendy Franiko

CASE REPORT
Patients Identity and Parents
Data
Name
Age

Pasien
Child. F
1
year

Sex
Address
Religion
Ethnic
Education

months
Female
Male
Jl. Kb Jahe, Kapuk, Cengkareng
Islam
Islam
Java
High School

Occupation
Information

Ayah
Mr. K
6 40 years

Relationship
with
parents
Biological
Child

Driver
Biological

the Father
:

Ibu
Mrs. PA
32 years
Female
Islam
Sunda
Secondary
School
Housewife
Biological
Mother

HISTORY
Primary
Complaint

Fever since 2 days before

entering the hospital

Additional
Complaint

Tightness, rash, cough, runny

nose, liquid defecation

History of Current Illness

Sudden fever ,
fever going up
and down, and
went down only
by
administering
febrifuge
Day I
06-11-2016

Day II
07-11-2016
Fever (+).
Coughing up
phlegm but the
sputum cannot be
taken out, a cold
with a runny nose
in translucent
colors. Skin rashes
ranging from face

Fever (+), red

eyes (+), Skin
rash spreads
throughout the
body. Liquid
defecation 45x / day
Day III >
Emergency Room
08-11-2016

Past History of Illness

Disease

Age

Disease

Allergy

Worm

Disease

Age

Diphtheria -

Heart

Diarrhea

Kidney

Infection
Dengue

Convulsion -

Blood

Fever
Thypoid

Ulcer

Pneumoni

a
Tuberculos -

Otitis

Varicella

Age

Kesan : Os tidak pernah dirawat dirumah sakitisdan sakit sebelumnya

Parotis
Surgery
Morbili
-

Family Disease History

No similar disease
History of Pregnancy and Birth
Pregnancy

Morbidity

Pregnancy
Antenatal care

Found
Checked every month to

Place of birth
Birth attendant
Means of childbirth
Period of gestation

midwives
Hospital
Physician
Spontaneous
36 weeks
Birthweight 2600 g

Body length 50 cm

Birth

of No

Head

Abnormalities

circumference:

forgot
Immediate tears
No
abnormalities

congenital

HISTORY OF GROWTH AND

DEVELOPMENT

History of Food
Age

Breastmilk/repla Fruit

/ Milk

Steamed

(month)
0-2

cement
Breastmilk

biscuits
-

porridge
-

rice
-

2-4

Breastmilk

4-6

Breastmilk

6-8

Formula milk

Biscuits

Porridge

8-10

Formula milk

Biscuits

Porridge

Note : the patients nutritional needs are adequately met

Immunization History
Vaccine
BCG
DPT

Basic (age)

Deuteronom

2 months
2 months

y (age)

x
4

x
6

month mont
POLIO

1 month

s
4

hs
6

month mont
MEASLES
HEPATITIS
B

x
After birth

s
x
1

hs
x
6

month mont
hs
Note : Basic immunization is incomplete

Riwayat Keluarga
Data
Nama
Perkawinan ke
Umur
Keadaan

Ayah
Tn. K
Pertama
40
Baik

Ibu
Ny. PA
Pertama
32
Baik

kesehatan
Kesan : Keadaan kesehatan kedua orang tua dalam keadaan
baik

RIWAYAT PERUMAHAN DAN

SANITASI
Tinggal di rumah sendiri. Terdapat tiga kamar. Ventilasi baik,
cahaya matahari cukup, air minum dan air mandi berasal dari
air tanah.
Kesan : Kesehatan lingkungan tempat tinggal pasien cukup
baik

Physical
Examination
Keadaan umum
: Tampak sakit sedang
Tanda Vital
Kesadaran
: compos mentis
Frekuensi nadi
: 132x/menit
Tekanan darah
: Tidak dihitung
Frekuensi pernapasan : 35x/menit
Suhu tubuh
: 38C
Data antropometri
Berat badan
: 6 kg
Panjang badan
: 73 cm

Physical Examination
Head Normocephali

Hair

Reddish black, hair is not easily to remove, good hair distribution

Conjungtiva anemis -/-, sclera icteric -/-, pupil isokor, RCL +/+, RCTL +/+,
lakrimasi +/+, Conjungtiva Injection +/+
Eye

Ear

Normotia, ear wax -/-

Nose Septum deviasi (-), secretion +/+ translucent colour

Dry lips (-),pharyngeal hiperemia (+), kopliks spot (+), tonsil T1/T1, kripta -/-,
Mouth detritus -/-

Face

Maculopapular rash (+)

Thorax

Cor

Inspection :chest movement static and dynamic,

symmetric, Retraction sub costal (+),
Maculopapular Rash (+)
Palpation : Percussion : Auskultation
:Vesicular breathing sound, ronkhi
basah +/+, wheezing -/-

Inspection : doesnt seem ictus cordis pulsation

Palpation : ictus cordis palpabe ICS V, linea
midclavicula sinistra
Percussion : Auscultation
: BJ I-II murni reguler, gallop (-),
murmur (-)

Abdomen

Inspection
Auscultaion
Palpation
membesar
Percussion

: Perut datar, makulopapular rash (+)

: Bising usus (+)
: Supel, turgor kulit baik, hepar dan lien tidak teraba
: Timpani di seluruh lapang abdomen

Icteric (-), petechie (-), maculopapular rash (+)

Skin

Warm extremity, cyanosis (-), edema (-), CRT < 2

Extremity

Supporting Examination
Check Lab 08/11/2016, 01.54
pm
Jenis

Hasil

Nilai Normal

Pemeriksaan
HEMA I

Leukosit

15,3 ribu/uL

6,0 17,0 ribu/uL

Hemoglobin

10,8 g/dL

10,8 12,8 ribu/uL

Hematokrit

35 %

35-43

Trombosit

222 ribu/ L

229-553 ribu/uL

Emergency
Department

Supporting Examination
Check Lab 08/11/2016, 08.00
pm
Jenis Pemeriksaan
Elektrolit

Hasil

Nilai Normal

Na

133

136 146 mmol/L

mmol/L

3,5 5,0 mmol/L

Chlorida

3,2 mmol/L 94 111 mmol/L

109
mmol/L

Emergency
Department

Supporting Examination
Check Lab 08/11/2016, 10.00
pm
Jenis Pemeriksaan
HEMA I

Hasil

Nilai Normal

Leukosit

21,3 ribu/uL 6,0 17,0 ribu/uL

Hemoglobin

11,9 g/dL

10,8 12,8 ribu/uL

Hematokrit

36 %

35-43

Trombosit

364 ribu/ L 229-553 ribu/uL

Sirsaks Room

Posteroanterior Thoracic Radiograph (08/11/2016)

Findings :
- the bronchovascular patterns of lungs are rough ( with
pulmonal infiltrate ) at both lungs.
Sinus and diafraghma normal
Cor and aorta : normal configuration
Lungs : there is no coin lession
Pleura : normal
Bones and soft tissue normal

Working
Diagnosis
Measles with secondary infection
Bronchopneumonia

Differential Diagnosis

Measl
es

Rubella

Bronchopneumo
nia
Pulmonary
Tuberculosis

Therap
y
Non mediamentosa
Education :
- Explain about the
disease
- Explanation about food
supply and vitamin
- explain to take medicine
every day according to
the doses administered
that treatment is
complete and the
complications will not
occur

Medikamentosa

Kaen 3B 300cc/hr
Amikasin 2 x 25 mg IV
Vitamin A 1x100.000 IU for
2 days
Cefotaxime 2x300 mg IV
Parasetamol3 x 0,6 ml
C : P ( 3 x / hr )
Zinc 1 x 20 mg

Follow Up (9-11-2016)
Date
9/11/2016

Day ( 2 ) of
Hospitalizat
ion

Subjective
Fever (+)
days 4
Cough (+)
days 3
Rash (+) days
3
Diarrhea 4x,
Before 5x/24
hours.
Eat - , drink -

Objective
Assesment
KU : TSS
Measles with
Kes : CM
secondary infection
HR : 108 x/m
Bronchopneumonia
RR : 33 x/m
S : 38*C
Head :
normocephali,
Small fontanelle :
dbn
Eye : CA -/-, SI -/-,
conjungtiva
injection +/+,
hollow eye (-).
Nose : deviation
(-), sekretion (+)
Ear : Normotia,
secretion (-).
Throat :
pharyngeal
hiperemia (+), T1T1
Thorax :
Symmetric,
Retraction sub
costal (+)
Pulmo : Rh +/+, wh
-/-, Vesicular

Planning
Vitamin A
1x100.000 IU
( 2 days )
Paracetamol 4 x
0,6 ml
Cefotaxim 2 x
300 mg IV
Zinc 1 x 20 mg
Amikasin 2 x 25
mg IV
Inhalasi/8jam
(C 3 : 1P)
KAEN 3B 300
cc/24 hours
After 2 days AB
treatment
( Check Hema 1
)

Follow
Follow Up
Up (10
(10 November
November 2016
2016 ))

Date
10/11/2016
Day ( 3 ) of
Hospitalizat
ion

Subjective
Fever (+)
days 5
Cough (+)
days 4
Rash (+) days
4
Diarrhea 4x,
Before 5x/24
hours
Eat -, drink

Objective
KU : TSS
Kes : CM
HR : 108 x/m
RR : 33 x/m
S : 38,2*C
Head :
normocephali,
Small fontanelle :
dbn
Eye : CA -/-, SI -/-,
conjungtiva
injection -/-, hollow
eye (-).
Nose : deviation
(-), sekretion (+)
Ear : Normotia,
secretion (-).
Throat :
pharyngeal
hiperemia (+), T1T1
Thorax :
Symmetric,
Retraction sub
costal (+)
Pulmo : Rh +/+, wh
-/-, Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur
(-)

Assesment
Measles with
secondary infection
Bronchopneumonia
+ GEA without
dehidration

Planning
Vitamin A
1x100.000 IU
( 2 days )
Paracetamol 4 x
0,6 ml
Cefotaxim 2 x
300 mg IV
Zinc 1 x 20 mg
Amikasin 2 x 25
mg IV
Inhalasi/8jam
(C 3 : 1P)
After 2 days AB
treatment
( Check Hema 1
)
KAEN 3B 300
cc/24 hours

Follow Up ( 11 11 2016 )

Date
11/11/2016

11/11/2016
Day
Day (( 4
4 )) of
of

Hospitalizati
Hospitalizati
on
on

Subjective
Fever (+)
days 6
Cough (+)
days 5
Rash (+) days
3 Diarrhea 2x.
Before 4x/24
hours
Eat drink

Objective
KU : TSS
Kes : CM
HR : 106 x/m
RR : 28 x/m
S : 37,8*C
Head : normocephal,
small fontanella : dbn.
Eye : CA -/-, SI -/-,
conjungtiva injection
-/-, hollow eye (-).
Nose : deviation (-),
sekretion (+)
Ear : Normotia,
secretion (-).
Throat : Pharyngeal
hiperemia (-), T1-T1
Thorax : Symmetric,
Retraction sub costal
()
Pulmo : Rh (+/+) , wh
-/-, Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur (-)
Abdomen : BU (+) N,
supel, NT (-)
Ext : Warm extremity,
edema (-)

Assesment
Measles
Measles with
with
secondary
secondary
infection
infection
Bronchopneumo
Bronchopneumo
nia
nia +
+ GEA
GEA
without
without
dehidration
dehidration

Planning
Paracetamol
Paracetamol 4
4
x
0,6
ml
x 0,6 ml
Cefotaxim
Cefotaxim 2
2x
x
300
mg
IV
300 mg IV
Zinc 1
1x
x 20
20 mg
mg
Zinc
Amikasin
Amikasin 2
2x
x
25
mg
IV
25 mg IV
Inhalasi/8jam
Inhalasi/8jam
(( C
C 3
3 :: 1
1P
P
))
KAEN
KAEN 3B
3B 300
300
cc/24
hours
cc/24 hours

Hema 1 Result After 2

days AB
Hb : 9,5 g/dL
Ht : 30 %
Leukosit : 5,9 rb/uL
Trombosit : 203 ribu/uL

Follow Up ( 12 11 2016 )

Date
12/11/2016
12/11/2016
Day
Day (( 5
5 )) of
of
Hospitalizati
Hospitalizati
on
on

Subjective
Fever
Fever (-)
(-) days
days
7
7
Cough
Cough (+)
(+)
days
6
days 6
Rash (+)
(+) days
days
Rash
4
4
Diarrhea
Diarrhea 0x.
0x.
Before
2x/24
Before 2x/24
hours
hours
Eat
Eat -,
-, drink
drink +
+

Objective
KU : TSS
Kes : CM
HR : 114 x/m
RR : 29 x/m
S : 36,8*C
Head : normocephal,
small fontanella : dbn.
Eye : CA -/-, SI -/-,
conjungtiva injection
-/-, hollow eye (-).
Nose : deviation (-),
sekretion (+)
Ear : Normotia,
secretion (-).
Throat : Pharyngeal
hiperemia (-), T1-T1
Thorax : Symmetric,
Retraction sub costal
()
Pulmo : Rh (+/+) , wh
-/-, Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur (-)
Abdomen : BU (+) N,
supel, NT (-)
Ext : Warm extremity,
edema (-)

Assesment
Measles
Measles with
with
secondary
secondary
infection
infection
Bronchopneumo
Bronchopneumo
nia
nia +
+ GEA
GEA
without
without
dehidration
dehidration

Planning
Paracetamol
Paracetamol 4
4
x
0,6
ml
x 0,6 ml
Cefotaxim
Cefotaxim 2
2x
x
300
mg
IV
300 mg IV
Zinc 1
1x
x 20
20 mg
mg
Zinc
Amikasin
Amikasin 2
2x
x
25
mg
IV
25 mg IV
Inhalasi/8jam
Inhalasi/8jam
(( C
C 3
3 :: 1
1P
P
))
KAEN
KAEN 3B
3B 300
300
cc/24
hours
cc/24 hours

Follow Up ( 13 11 2016 )

Date
13/11/2016

13/11/2016
Day
Day (( 6
6 )) of
of

Hospitalizati
Hospitalizati
on
on

Subjective
Fever (-) days
7
Cough (+) days
6
Rash (+) days
4
Hiperpigmentat
ion
Eat Drink +

Objective
KU : TSS
Kes : CM
HR : 104 x/m
RR : 27 x/m
S : 37,4*C
Head : normocephal,
small fontanella :
dbn.
Eye : CA -/-, SI -/-,
conjungtiva injection
-/-, hollow eye (-).
Nose : deviation (-),
sekretion (+)
Ear : Normotia,
secretion (-).
Throat : Pharyngeal
hiperemia (-), T1-T1
Thorax : Symmetric,
Retraction ( - )
Pulmo : Rh (+/+) , wh
-/-, Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur (-)
Abdomen : BU (+) N,
supel, NT (-)
Ext : Warm extremity,
edema (-)

Assesment
Measles
Measles with
with
secondary
secondary
infection
infection
Bronchopneumo
Bronchopneumo
nia
nia +
+ Febris
Febris ec
ec ?
?

Planning
Paracetamol
Paracetamol 4
4
x
0,6
ml
x 0,6 ml
Cefotaxim
Cefotaxim 2
2x
x
300
mg
IV
300 mg IV
Zinc 1
1x
x 20
20 mg
mg
Zinc
Amikasin
Amikasin 2
2x
x
25
mg
IV
25 mg IV
Inhalasi/8jam
Inhalasi/8jam
(( C
C 3
3 :: 1
1P
P
))
KAEN
KAEN 3B
3B 300
300
cc/24
hours
cc/24 hours
Consul
Consul Sp.THT
Sp.THT
Vitamin A
A
Vitamin
1x100.000
1x100.000 IU
IU

Follow Up ( 14 11 2016 )

Date
14/11/2016

14/11/2016
Day
Day (( 7
7 )) of
of

Hospitalizati
Hospitalizati

on
on

Subjective
Fever (-) days
8
Cough days 7
Hiperpigmentat
ion
THT : normal.
Eat , drink +

Objective
KU : TSR
Kes : CM
HR : 101 x/m
RR : 26 x/m
S : 36,5*C
Head : normocephal,
small fontanella : dbn.
Eye : CA -/-, SI -/-,
conjungtiva injection
-/-, hollow eye (-).
Nose : deviation (-),
sekretion (+)
Ear : Normotia,
secretion (-)
Throat : Pharyngeal
hiperemia (-), T1-T1
Thorax : Symmetric,
Retraction ( - )
Pulmo : Rh (+/+) , wh
-/-, Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur (-)
Abdomen : BU (+) N,
supel, NT (-)
Ext : Warm extremity,
edema (-)

Assesment
Measles
Measles with
with
secondary
secondary
infection
infection
Bronchopneum
Bronchopneum
onia
onia

Planning
Paracetamol
Paracetamol
4
4x
x 0,6
0,6 ml
ml
Cefotaxim
Cefotaxim 2
2x
x
300
mg
IV
300 mg IV
Zinc
Zinc 1
1x
x 20
20
mg
mg
Amikasin
Amikasin 2
2x
x
25
mg
IV
25 mg IV
KAEN
KAEN 3B
3B 300
300
cc/24
hours
cc/24 hours
Vitamin
Vitamin A
A
1x100.000
1x100.000 IU
IU

Follow Up ( 15 11 2016 )

Date
15/11/2016

Day ( 8 ) of
Hospitalizati

on

Subjective
Fever (-) days
9
Cough days 8
Hiperpigmentat
ion
Eat Drink +

Objective
KU : TSR
Kes : CM
HR : 110 x/m
RR : 26 x/m
S : 36,7*C
Head : normocephal,
small fontanella : dbn.
Eye : CA -/-, SI -/-,
conjungtiva injection
-/-, hollow eye (-).
Nose : deviation (-),
sekretion (+)
Ear : Normotia,
secretion (-)
Throat : Pharyngeal
hiperemia (-), T1-T1
Thorax : Symmetric,
Retraction ( - )
Pulmo : Rh (-/-), wh -/-,
Vesicular
Cor : BJ I-II Regular,
Gallop (-), Murmur (-)
Abdomen : BU (+) N,
supel, NT (-)
Ext : Warm extremity,
edema (-)

Assesment
Measles with
secondary
infection
Bronchopneum
onia

Planning
Zinc 1 x 20
mg

PROGNO
SIS
Ad vitam

: ad bonam

Ad fungsionam : ad bonam

Ad sanationam : dubia ad bonam

Resume
F came to the emergency department saying that she had a fever 2
days before entering the hospital, the fever came so sudden, and the
fever was decreased by administering febrifuge but then the fever came
back with high temperature. one day before entering the hospital, the
mother said that red spots occurred starting from the face and
coughing up phlegm. Six hours before entering the hospital, oss
mother said that oss eyes were red and the red spots had already
contained the whole body. Liquid defecating for 4 5 times.
Incomplete immunization history, immunization of measles (-).
Physical examination obtained common condition of mild illness, general
awareness of compos mentis, febrile, conjunctival injection +/+,
secretions +/+ transparent color, lips did not look dry, pharyngeal
hyperemia (+), kopliks spot (+), wet pulmonary crackles +/+, skin
of the face, neck, chest, abdomen, and extremities maculopapular rash
(+). In laboratory tests on 8 11 - 2016, at 1 pm obtained
leukocytes 15,3 rb/L, hemoglobin 10.8 g /dL, hematocrit 35%,
platelets 222 rb / uL. Photos of roentgen thoracic PA image of
bronchopneumonia and in the laboratory tests on 8 11 2016,
at 10 pm obtained leukocytes 21.3 rb / mL, hemoglobin 11.9 g /
dL, hematocrit 36%, platelets 364 rb / uL.

Case Analysis

Diagnosis

Anamnes
is
Physical
Examinatio
n
Supporting
Examintaion

HISTORY AND PHYSICAL

EXAMINATION
Morbili is an acute viral infection
characterized by 3 stages

Prodromal
stadium

Eruption
stadium

Convalesce
nce stadium

Prodromal stadium(4-5
days)
Febris > 38,5C

Fever at home
is not
measured

Cough, coryza

Coughs and
colds

Conjunctivitis

Red eyes,
watery, and a
yellowish
white color
substance
generated

End of the
catarrhal
stage, no
koplic spots

Not found

Leukopenia /
normal
leukocytes and
mild
lymphocytosis
due to viral
infection

Leukocytes61
00
thousand/L
and
lymphocytes
60

Eruption stadium3-4 days

Patients
fever gets
higher

Fever 39,2C

Coughs
increased

Coughs
increased to
tightness

Maculopap
ular rash
(+)

Red spots
appeared on
the back of the
ear and spread
to the face,
neck, body,
and to the foot

Stadium Convalescence
Hyperpigment
ation

Red spots
turned to
blackening
starting from
behind the
ears, the skin
gets scaly

Fever dropped

Temperature
37,5C

EPIDEMIOLOGI

PATHOPHYSIOLOGY
Paramyxovirus virus
Droplet of Infections enters the
airways
Captured by macrophages
Spreads to regional lymph nodes
Viral
replication
Primary
viremia
Affecting the temperature center in the
hypothalamus
Center set point of
temperature increases
Body temperature
incerases
Secondary viremia
Gastrointestinal respiratory

Skin

Conjunctiva

GASTROINTESTI
NAL
Proliferation of
capillary
endothelial
cells
Contained
gray Koplik
spots surrounded by
erythema on the
mucosa bukalis faced
with molar, hard palate,
soft palate
Bitter
mouth

anorexia

Lack of hygiene and low

immunity will extend to the
gut
Hyperplasia of lymphoid tissue,
especially in appendectomy thus
the intestinal mucosa is irritated

speed of secretion increases

Increased bowel movement diarrhea dehydration

REPIRATORY
TRACT
Upper respiratory tract
inflammation
Koplik spots extends to
tracheobronchial
Cilia function declines
Secretion increases
Cough, runny nose, RR
increased

Necrotic epithelial area in th

nasopharynx and respirator
tract
Secondary
bacterial
infection
bronchopneumoni
attacks
a

SKIN

Exudation of serum and

occasionally erythrocytes
into the epidermis
Stand out skin around
sebaceous and hair
follicles
Erythema forming of
macular papules in
normal skin
Rash in the area behind the
ears, neck, face, the whole
body

CONJUNCTIVA

General inflammation in
the conjunctiva
Eye dirt, photophobia
Conjunctivitis

PROCEDURES

Rest

Provision
of
adequate
fluids

Nutritional
suppleme
nts

Antibiotics
are given
if there is
secondary
infection

Anti
convulsive
if there is
convulsion
s

Vitamin A
for 3 days
Antipyreti
cs when
fever

200 000 IU
age 12
months
100 000 IU
baby 6 to
11 months
50 000 IU
age <i6
months

IMUNISASI

Thank You