CASE

AAG, a 7 years 11 months old boy, BW : 48 kg, BH : 136 cm, came to

USU Hospital on January 7th at 6 pm. His main complaint was skin rash.
History of disease :
The skin rash has been experienced by patient for 1 day before being
admitted to USU Hospital. The rash appears as red, maculopapular, itchy,
and slowly spreads from face at hairline to the neck and trunk
Fever was experienced 6 days ago, fever was high in the first day,the
highest was 38,6C and responded to antipyretic drug, shivering (-),
convulsion (-)
Cough (+) since 3 days ago, sputum (-), runny nose (-).
Red eyes (+) was experienced 3 days ago, ichy (-), pus (-)
Vommiting (-). Nausea (-). Diarrhea (-).
History of having contact with measles patient was found, 2 weeks ago.
Urination and defecation within normal
History of medication :
Patient was given paracetamol everytime fever was felt high.
History of previous disease :
History of family : His cousin got similar signs and symptoms
History of pregnancy :
Patient is a first child from 2 siblings. During pregnancy mother is 22 years
old. During pregnancy the mothers confirms no Hypertension, fever, DM or
had medicine consumption. Ante natal care (+) to midwife.
History of birth :
Birth was assited by a midwife. Spontaneously per vaginam and cried
immediately after birth. History of cyanosis (-). Body weight at birth was
3600gram, body length was 51 cm and head circumference was not well
known.
History of feeding :
Breast milk was given until 24 months (8 times a day) with formula feeding
(4-5 times a day). Then patient was given milk porridge and formula feeding
from 6 months until 9 months old, frequency 4-5 times a day. After 9 months
old patient was given steam porridge, frequency 4-5 times a day. Family food
was given since patient was 18 months old.
History of growth and development :
According to patients mother, growth and development was normal. Mother
can not remember well, but patient could stand up at 1 years old and walk at 1

3
 year 6 months old.
Hitory of immunization :
BCG scar (+), Polio (+) four times, Hepatitis B (+) three times, DPT (+) four
times, Measles (+) once

Physical Examination
Sens : Awareness, Temperature :36,1C
BW/A : 133 % (overweight), BH/A :95 % (normal), BW/BH : 160% (obesity)
Head : In normal morphologic.
Eye : Light reflex (+/+), isochoric pupil ( R:3mm ,L: 3 mm),
pale inferior palpebral conj. (-/-), hiperemis sclera (+),
Ears : Both ear in normal morphologic. Serumen (+) in normal.
Nose : Septum deviation (-), normal morphologic.
Mouth : Cyanosis (-), dry mouth (-)
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiform, retraction (-)
HR: 96 bpm, regular, murmur (-/-)
RR: 20 bpm, regular, ronchi (-/-), wheezing (-/-).
Abdomen : Soepel, peristaltic (+) N, hepar & lien : unpalpable.

Extremities : BP: 110/70, Pulse 96 bpm, regular, adequate p/v,felt

warm, CRT <3, oedema (-/-)
Skin : maculopapular rash (+) on ear lobe, face, neck, thoraks
and superior extremities.

Differential Diagnose :
1. Measles + Obesity
2. Rubella + Obesity
3. Miliaria + Obesity

Working Diagnose : Measles + Obesity

Therapy : Bed Rest (isolated room)
Diet MB 2000 kkal
IVFD D5% 41 gtt/i mikro

4
 Vitamin A 100.000 IU /oral (single dose)
Dextrometorpan 15 mg tab (3x1 hari)

Planning : Whole blood count

Thoraks X-Ray