Case report

Morbili
Dian Indra Malik R.
k1B122095
 Patient identity
Name. : An. Muh Rafathar
Date of Birth : 27/12/ 2017
Age. : 6 years
Gender : Boy
Weight : 19 kg
Height : 120 cm
Religion : Islam
Tribe. : Tolaki
Address : Jln. Cumi-Cumi no.II
Medical Record Number : 108XXX
Date get in hospitalization : 02 Feb 2023
Pediatric Doctor : dr. Wa Ode Sitti Asfiah Udu, M.Sc., Sp.A
 Anamnesis
Aloanamnesis

Chief Complement:

Fever

A boy 6 y.o came to emergency room Santa Anna Hospital with

complaints of fever since 5 days ago (Monday morning). At First day of
fever (Monday night) a boy have reddish rash/spot appears on the
stomach and then spreads to the legs. On Tuesday, a kind of white
coating appeared on the tongue and inside of mouth and the Spots feel
itchy (+). Other complains Cough (+) with phlegm since Wednesday
morning. Cold (+), pain swallowing (+), bleeding on his lips (+) from 2 days
ago because lips are dry. Nausea (-), vomiting (-), stomach pain (-). Last
bowel movement (-) 5 days ago (last Monday). BAK Normal. Decreased
appetite. Long (+). there is a thrush on the right buccal.
 Medical History
•Treatment history: (+) Paracetamol
•Past medical history: (-)
•History of family contact with the same complaint: (-)
•Prenatal : History of growth and development with normal
limits. He received Hepatitis B, BCG, polio, and DPT
 Physical Examination
KU: Moderate Disease, Compos Mentis

Antropometri:
Weight: 19 kg, Height: 120 cm

Nutrition Status:
Weight/Age : Normal
Lenght/Age : Normal
Weight/Lenght : Normal

Vital Signs :
TD: 90/60 mmHg S : 39,0 oC
N : 147x/m SpO2: 97%
P : 24 x/m
 Physical Examination
STATUS GENERALIS

Head Normocephal

Eyes anemic conjunctiva (-), Subconjunctival hemorrhage (-),

Icteric sclera (-).

Nose Rinorhea (-/-), nasal flare (-), epistaxis (-/-)

Ears Otorhea (-/-), othalgia (-/-)

Mouth Lips Cyanosis (-), pale (-), dry (-)

Larynx Hyperemic (+),

T1/T1 Hyperemic (-)
Tonsils
Neck Lymph nodes enlargement (-)
 Physical Examination
Lung Normochest, Symmetrical left and right, retraction (-)
Pressive pain (-), Mass (-), crepitation (-)
Sonor on both lung
Vesicular (+/+), Rhonki (-/-), Wheezing (-/-)

Ictus cordis not visible

Ictus cordis not palpable
Heart Right cord border at ISC IV LPSD, left cord border at ICS V LMCS
Heary sound I/II regular, murmur (-)

Flat, follow the breath

Abdomen peristalsis (+) normal impression
Timpani, ascites (-)
epigastric tenderness (-), mass (-), organ enlargement (-)
Skin Icteric (-), petechie (-), pale (-), rash (-)
Extremity Warm acral, edema (-), CRT <2 seconds
 Resume
•A boy 6 y.o came to emergency room Santa Anna Hospital with complaints of fever
since 5 days ago (Monday morning). At First day of fever (Monday night) a boy have
reddish rash/spot appears on the stomach and then spreads to the legs. On Tuesday, a
kind of white coating appeared on the tongue and inside of mouth and the Spots feel
itchy (+). Other complains Cough (+) with phlegm since Wednesday morning. Cold (+),
pain swallowing (+), bleeding on his lips (+) from 2 days ago because lips are dry, there
is a thrush on the right buccal.
• Treatment history: (+) Paracetamol ½ tab 500mg 1x1
• Past medical history: (-)
• History of family contact with the same complaint: (-)
• Prenatal : History of growth and development with normal limits. He received Hepatitis B, BCG,
polio, and DPT
 Diagnosis
Obs. Febris + Susp. Morbili

Treatment
IVFD RL 20 tpm
Inj. Paracetamol (19 cc)/ IV
Inj. Ranitidin 1/3 amp/8 Jam
Ibuprofen 2x100 mg
Cefixim 2x3 ml
Imboost Force 1x5 ml
Nystatin drops 3x0,5ml
Cetirizine 1x1
 Follow up
03/02/24 S : Fever (+) cough (+) with phlegm since Wednesday morning, P :
pain swallowing (+). Reddish spots on the stomach and legs. IVFD RL 20 tpm
The spots feel itchy. liquid defecation (-). Urination in normal Inj. Paracetamol (19 cc)/ IV
limits. Don't want to eat food + take medicine because my lips
are dry so I can't open my mouth wide.
O : Moderate pain
TD: 110/80 mmHg
N : 118 x/m
P : 30 x/min
S : 38,4 oC
SpO2 : 98%
Nose : Rinorrhea (-/-), nasal flaring (-),
Mouth : dry (-), cyanosis (-), pale (-)
Larynx: Hyperemic (+), Tonsils T1/T1 Hyperemic (-)
Lung : retraction (-), Sonor (+/+), Vesicular (+/+), ronkhi
(-/-), wheezing (-/-).
Abdominal: flat, follow breathing, peristalsic (+) normal
impression, Timpani (+), tenderness (-), organ
enlargement.
Extremity : Warm acral, edema (-), CRT <2 seconds

A : Obs Febris H-5 + Susp. Morbili

 Follow up
03/02/24 S : : Fever (-) cough (+) with phlegm since Wednesday P :
morning, pain swallowing (+). Reddish spots on the stomach IVFD RL 20 tpm
and legs. The spots feel itchy. liquid defecation (-). Urination Inj. Paracetamol (19 cc)/ IV
in normal limits. Don't want to eat food + take medicine
because my lips are dry so I can't open my mouth wide.
O : Moderate pain
TD: 110/80 mmHg
N : 118 x/m
P : 26 x/min
S : 36,8 oC
SpO2 : 99%
Nose : Rinorrhea (-/-), nasal flaring (-),
Mouth : dry (-), cyanosis (-), pale (-)
Larynx: Hyperemic (+), Tonsils T1/T1 Hyperemic (-)
Lung : retraction (-), Sonor (+/+), Vesicular (+/+), ronkhi
(-/-), wheezing (-/-).
Abdominal: flat, follow breathing, peristalsic (+) normal
impression, Timpani (+), tenderness (-), organ
enlargement.
Extremity : Warm acral, edema (-), CRT <2 seconds

A : Obs Febris H-5 + Susp. Morbili

 Follow up
03/02/24 S : Fever (-) cough (+) with phlegm since Wednesday morning, P :
pain swallowing (+). Reddish spots on the stomach and legs. IVFD RL 20 tpm
The spots feel itchy. liquid defecation (-). Urination in normal Inj. Paracetamol (19 cc)/ IV
limits.
O : Moderate pain
TD: 110/80 mmHg
N : 118 x/m
P : 30 x/min
S : 38,4 oC
SpO2 : 98%
Nose : Rinorrhea (-/-), nasal flaring (-),
Mouth : dry (-), cyanosis (-), pale (-)
Larynx: Hyperemic (+), Tonsils T1/T1 Hyperemic (-)
Lung : retraction (-), Sonor (+/+), Vesicular (+/+), ronkhi
(-/-), wheezing (-/-).
Abdominal: flat, follow breathing, peristalsic (+) normal
impression, Timpani (+), tenderness (-), organ
enlargement.
Extremity : Warm acral, edema (-), CRT <2 seconds

A : Obs Febris H-5 + Susp. Morbili

Literature Review
 Morbili
Measles is an acute, viral, infectious disease. It is caused by a paramyxovirus virus,
manifesting as a febrile rash illness. The incubation period for measles usually
is 10–14 days (range 7–23 days) from exposure to symptom onset (1). Initial
symptoms (prodrome) generally consist of fever, malaise, cough, conjunctivitis,
and coryza. The characteristic maculopapular rash appears two to four days after
onset of the prodrome.
 Epidemiology

Since 2022, Indonesia has recorded an increase in

suspected and confirmed measles cases compared to
previous years. Between 1 January and 3 April 2023, a total of
2161 suspected measles cases (848 laboratory-confirmed and
1313 clinically compatible [suspected]) have been reported
across 18 of 38 provinces in Indonesia.
 Patophysiology
Once the virus penetrates the organism through the nasopharyngeal or conjunctival
mucosa, it utilizes the H glycoprotein to bind and attach to host cells. The first area it
reaches is the regional lymph nodes where it infects lymphocytes, multiplies, and
starts to spread systematically. The virus then reaches the lymphoreticular cells of
the spleen, liver, bone marrow, and other organs.
 Clinical Manifestations

The clinical picture of measles can be divided into three

stages: prodromal, eruptive, and convalescent and should be
suspected in patients with the classic triad of the three “Cs”:
cough, conjunctivitis, and coryza. The primary or prodromal
phase lasts four to six days and is characterized by the
presence of high fever, malaise, coryza, conjunctivitis,
palpebral edema, and dry cough. Most cases show the
characteristic Koplik spots of the disease, located in the buccal
mucosa at the height of the second molar, and appear two to
three days before the rash and disappear on the third day.
 Management

he mainstay of measles treatment is prevention via routine

immunization, which is highly effective in the prevention of
measles. For children, vaccination begins with the first dose between
the ages of 12 to 15 months followed by a second dose at 4 to 6 years
of age though it can be administered as early as 28 days after the first
dose if the patient is above 12 months of age.
There is no specific treatment of measles except supportive care
to relieve common symptoms associated with this condition.
Supportive measures include antipyretics for fevers, hydration, and
adequate nutritional support, including the encouragement of
breastfeeding.
Terima Kasih