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(MEASLES)
MINI POSTER
F A D I A H G A Z Z AN I R A H MA N ( C 1 1 1 1 0 8 0 9 ) D Z U L F I KA R W A S P A D A (110 208 040)
Patient Identity...
Name Gender Age Marital status Religion Address Occupation Addmission date Medical record no
: Mr. YL : male : 52 years old : married : christian : jl. Singa : government officer (PNS) : October 10, 2013 : 379352
History Taking
Main Complaint : red rash on all parts of the body (face, arms, legs, chest, back, stomach)
Brief Anamnesis : Occur since 2 days ago before hospitalized Itchy (-), pain (-) Drugs allergy (-), food allergy (-) History of complaint with the same symptoms (-) Medication for the symptoms (-) Family with the same symptoms (-) Previous Medical History : The patient suffer from chronic heart failure (CHF) NYHA II and consume Lasix and Alprazolam
Current Status
Consciousness Hygiene
General Condition
Nutrition
Vital sign
: compos mentis : moderate : moderate : normal : 130/90 mmHg : 80x/minutes : 28x/minutes : 380C
BP Pulse RR Temperature
Physical Examination
Anemic (-), icterus (-), cyanoses (-) Cor Thorax Abdomen
Extremities
Lymph nodes
: chronic heart failure NYHA II : symmetrical : ronchi (-), wheezing (-) : normal, peristaltic (+) : edema (-) : enlargement (-)
Facial Region
Thoracoabdominal region
Arms Region
Legs Region
Dermatovenerology Status
Region Efflorescence : generalized : erythematous macule
Resume
A man 52 years old entered the hospital with main complaint red rash on all parts of the body (face, arms, legs, chest, back, stomach) that occured since 2 days ago before hospitalized. The rash are not itch and the patient doesnt feel pain. The patient has no allergic to food neither drugs. He never felt the same complaint before and no family suffer the same complaint. Previous medical history : The patient suffer from chronic heart failure (CHF) NYHA II and consume Lasix and Alprazolam
Diagnosis
MORBILLI
Discussion
Morbilli, also known as rubeola or measles, is one of
the most contagious infectious diseases that caused by measles virus. Morbilli is marked by prodromal fever, cough, coryza, conjunctivitis, and pathognomonic enanthem (ie, Koplik spots), followed by an erythematous maculopapular rash on the third to seventh day. Infection confers life-long immunity.
Etiology
The cause of morbilli is the measles virus, a singlestranded, negative-sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae. Humans are the natural hosts of the virus; no animal reservoirs are known to exist. This highly contagious virus is spread by coughing and sneezing via close personal contact or direct contact with secretions.
Recommended Examination
Serologic testing for IgG and IgM antibodies
Viral culture
Prognosis
Bonam (good)