TEMPORARY TUTORIAL REPORT SCENARIO C BLOCK 7

GROUP 10

Tutor : dr. Thia Prameswarie, M. Biomed

Members :

Fransiska Delvia 702018020

Nadhea Yolanda Puspita 702021019

Stievy Arifin 702021027

Faris Fathin 702021032

Malika Zilda 702021047

Shafa Noermedina Magfirah 702021069

Adinda Fatimah Azahra 702021076

Ahmad Fadhil Kurnia 702021089

Dzakiyyah Fajriah Azhar 702021092

Putri Aprilia Kusuma Widyanti 702021105

FACULTY OF MEDICINE

MUHAMMADIYAH UNIVERSITY PALEMBANG

2021/2022
 INTRODUCTION

Praise and gratitude we pray to Allah SWT for all His mercy and grace, we
were able to complete the tutorial report entitled Tutorials Report Scenario E
Block VII as a group competency task. Salawat and greetings are always poured
out to our lord, the great prophet Muhammad SAW and his family, friends and
followers until the end of time.
We realize that this tutorial report is far from perfect. Therefore, we expect
constructive criticism and suggestions for future improvements. In completing this
tutorial report, the author received a lot of help, guidance and advice. On this
occasion, the author would like to express his respect and gratitude to:

1. Allah SWT, who has given us opportunities and blessings that we can still
feel today.

2. dr. Thia Prameswarie, M. Biomed as the supervising lecturer for the block
VII tutorial scenario C.

3. All parties involved and helped in completing this report.

In preparing this report, the author realizes that this report is still far from
perfect, in terms of material, as well as the arrangement of words. Therefore, all
forms of criticism and suggestions are highly expected to help us so that in the
future this tutorial report can be even better.

Palembang, 21 Juni 2022

Writer

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 TABLE OF CONTENTS

INTRODUCTION.................................................................................................... i

TABLE OF CONTENTS.........................................................................................ii

CHAPTER I............................................................................................................. 1

FOREWORD........................................................................................................... 1

CHAPTER II............................................................................................................2

DISCUSSION.......................................................................................................... 2

2.1 Data Tutorial.............................................................................................. 2

2.2 Case Scenario..............................................................................................2

2.3 Term Clarification.......................................................................................3

2.4 Problem Identification................................................................................ 4

2.5 Problem Priority..........................................................................................5

2.6 Problem Analysis........................................................................................5

2.7 Conclusion................................................................................................ 43

2.8 Conceptual Framework.............................................................................43

DAFTAR PUSTAKA............................................................................................ 44

ATTACHMENT.................................................................................................... 48

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 CHAPTER I

FOREWORD

1.1. Background
One of the learning strategies for the Competency-Based Curriculum system is
Tutorial. The tutorial is an implementation of the Problem Based Learning (PBL)
method. In the tutorial students are divided into small groups and each group is
guided by a tutor/lecturer as a facilitator to solve existing cases. On this occasion,
a scenario case study tutorial entitled "Reddish Rash" was carried out.
1.2. Aims and Objectives
The aims and objectives of this case study report are:
1. As a tutorial group assignment report which is part of the e-learning-
based learning system at the Faculty of Medicine, Muhammadiyah
University of Palembang.
2. Solve the cases given in the scenario using analysis methods and group
discussion learning.
3. The achievement of the objectives of the tutorial learning method.

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 CHAPTER II

DISCUSSION

2.1 Data Tutorial

Tutor : dr. Thia Prameswarie, M.
Moderator : Faris Fathin
Desk Secretary : Stievy Arifin
Board Secretary : Ahmad Fadhil Kurnia
Date : Senin, 9 Mei 2022
Time : 08.00-10.30

Tutorial Rules:
1. Mutual respect among fellow tutorial participants
2. Using good and appropriate communication
3. Raise your hand when you want to submit an opinion
4. Not activating communication tools during the tutorial process
5. Permission to leave the room
6. On time

2.2 Case Scenario

“Reddish Rash”
Mimi, a girl, aged 9 months, was brought by her mother to the outpatient
clinic of RSMP because of a fever and a red rash appeared on her skin. Fever
started 1 day ago and 10 hours later a red rash appears on the face and body.
There are no seizure, cough and cold. Previous immunization history, Mimi has
received BCG immunization 1 time, Hepatitis B 2 times, DPT 2 times, HiB 2
times and Polio drops 3 times and just received measles immunization 3 days ago.

Physical examination:
General Condition: Compost mentis, BW: 9 kg, BH: 75cm
Vital Signs: pulse 110 x/menit, RR: 28 x/menit, Temp: 38oC

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Head : Pale conjunctiva (-/-), rinorea (-).
Chest:
• Lung : within normal limits
• Heart : Normal first and second heart sounds, no murmurs
Abdomen: liver and spleen are not palpable
Extremities: within normal limits
Dermatological status: macular erythematous papules appear discrete on the face
and body

2.3 Term Clarification

No Term Meaning
1. Fever An increase in body temperature above normal
(Above 37o celcius).
2. BCG Bacille Calmette Guerin, a vaccine for tuberculosis
made from attenuated tuberculosis bacilli by
culturing in artificial media for many years.
3. Measles Rubeola, a highly contagious viral infection,
primarily affecting the respiratory tract and
reticuloendothelial tissue, characterized by eruption
of red papules.
4. Red rash Inflammation of the skin.
5. Immunization The process of making a subject become, immune, or
become immune with a specific antigen to induce an
immune response.
6. Cough Air expulsion from the sudden lungs while making a
loud noise.
7. Polio An acute viral disease, usually caused by the polio
virus and characterized by clinical symptoms of
fever, sore throat, headache, vomiting, and often
accompanied by neck and back stiffness.
8. Hepatitis B a potentially life-threatening liver infection caused by

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 the hepatitis B virus (HBV).
9. Seizure Stiffness and tension in the muscles.
10 HiB Himophilus influenza type B which can cause
inflammation of the lining of the brain.
11. DPT Tetanus toxoid vaccine and diphteria and pertussis.
12. Compost mentis Normal consciuosness,fully aware.
13. Murmurs Auscultative sounds, especially periodic sounds of
short duration and originating from the heart or blood
vessels.

2.4 Problem Identification

1. Mimi, a girl, aged 9 months, was brought by her mother to the outpatient
clinic of RSMP because of a fever and a red rash appeared on her skin.
Fever started 1 day ago and 10 hours later a red rash appears on the face
and body. There are no seizure, cough and cold.
2. Previous immunization history, Mimi has received BCG immunization 1
time, Hepatitis B 2 times, DPT 2 times, HiB 2 times and Polio drops 3
times and just received measles immunization 3 days ago.
3. Physical examination:
General Condition: Compost mentis, BW: 9 kg, BH: 75cm
Vital Signs: pulse 110 x/menit, RR: 28 x/menit, Temp: 38oC
Head : Pale conjunctiva (-/-), rinorea (-).
Chest:
• Lung : within normal limits
• Heart : Normal first and second heart sounds, no murmurs
Abdomen: liver and spleen are not palpable
Extremities: within normal limits
Dermatological status: macular erythematous papules appear discrete on
the face and body

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2.5 Problem Priority

No 1, Because fever and red rash are the main complaints and can interfere
with daily activities and complications can arise if not treated

2.6 Problem Analysis

1. Mimi, a girl, aged 9 months, was brought by her mother to the outpatient
clinic of RSMP because of a fever and a red rash appeared on her skin.
Fever started 1 day ago and 10 hours later a red rash appears on the face
and body. There are no seizure, cough and cold.
a. How about the anatomy physiology and histology of the case?
Answer :
Anatomy
1. Lymph vessels, basically are channels that carry fluids
clear or whitish, which is called lymph. This fluid enters the vessels by
diffusion into the small lymph capillaries that are interwoven between
the capillaries of the cardiovascular system. If it is already in the
lymphatic vessels, this fluid is called lymph, which is almost the same
composition as interstitial fluid. Sap This clear tissue helps in clearing
infective tissue organisms, toxins, and etc. The ducts are tubular, like
blood vessels covers all body tissues. Along the lymph vessels are
organs called lymph nodes (lymph nodes) that filter lymph. Within the
lymph nodes are honeycomb-shaped connective tissue with spaces
filled with white blood cells. Lymph nodes are located along the path
of lymph vessels in the form of oval objects or small round. The
function of these nodes is to filter antigens from the lymph and initiate
an immune response (Scnalon, 2007).
2. Lymphatic system, Broadly speaking the body's lymphatic system
can be divided into the conduction system, lymphoid tissue a lymphoid
organs. conduction system transports lymph and consists of tubular
vessels lymph capillaries, lymph vessels and thoracic duct. Almost all

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body tissues have vessels or lymph channels that drain fluid from the
interstitial space. Definition of lymphatic tissue (or often called
lymphoid tissue) is the reticular connective tissue that infiltrated by
lymphocytes. This lymphoid tissue is widely distributed throughout the
body. body either as a lymphoid organ or as a diffuse collection of
lymphocytes and solid. The lymphoid organ itself is a mass or
collection of lymphoid tissue surrounded by a connective tissue
capsule or lined by epithelium (Scanlon, 2007).

3 skins
Skin is composed of three layers: epidermis, dermis and hypodermis or
subcutaneous tissue.
1) Dermis: a layer of connective tissue that contains a lot of elastic
fibers (for stretching) and collagen fibers (for strength) as well as many
blood vessels and specialized nerve endings.
2) Epidermis: consists of many layers of epithelial cells that do not
have flow
Direct blood contains four types of cells: keratinocytes, melanocytes,
cells langerhans and granstrein cells.

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3) Hypodermis: - the tissue to which the skin is attached (muscle/bone)
or also known as subcutaneous tissue
- A layer of loose connective tissue
Some fat cells are found in the hypodermis, where there are presence
of fat or adipose tissue deposits.

Physiology:
a. lymph vessels
1. Collect and restore interstitial fluid, including plasma proteins into
the blood, thereby helping to maintain fluid balance
2. Defend the body against disease by produce lymphocytes.
3. Absorb fat from the intestine and carry it to the blood
4. Remove toxic substances and cellular debris from tissues after
infection or tissue damage
5. Lymph vessels control the quality of fluid flow by filter through the
lymph nodes before returning them to the circulation (Scanlon, 2007).

b. The lymph system is an additional pathway through which fluids

can be transported flows from the interstitial space into the blood as a
transudate where it then plays a role in the body's immune response. In
general, the lymphatic system has three functions:
1. Maintaining a low protein concentration in the interstitial fluid so
that blood proteins filtered by the capillaries will be retained in the
tissue, increasing the volume of tissue fluid and elevates interstitial

7
fluid pressure. The increase in pressure causes the lymph pump to
pump interstitial fluid into the lymph capillaries carrying the
accumulated excess protein. If this system does not function, the
dynamics of fluid exchange in the capillaries will become abnormal
within a few hours, leading to death
2. Absorption of fatty acids, transport of fat and chyle to the system
circulation
3. Produce immune cells (such as lymphocytes, monocytes, and
antibody-producing cells called plasma cells). lymph nodes prepares an
environment in which lymphocytes will receive exposure first against
foreign antigens (viruses, bacteria, fungi) that will activate
lymphocytes to carry out immune functions (Scanlon, 2007).

Skin function:
1) Protection
The skin that covers most of the body is about 1 . thick or only 2 mm,
even though the skin provides very good protection Effective against
bacterial invasion and other foreign bodies. Hand skin and thickened
soles provide highly effective protection to the effects of continuous
trauma that occurs in the area the.
2) Sensibility
The receptor endings of nerve fibers in the skin allow the body to
continuously monitor the state of the surrounding environment.
Function:
The main receptors on the skin are to sense temperature, pain, light
touch and pressure (or heavy touch).Various ends nerves are
responsible for reacting to any stimuli that different. Although
scattered throughout the body, the nerve endings are more
concentration in some areas compared to others
3) Fluid balance

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The stratum corneum has the ability to absorb water and This will
prevent excessive water and electrolyte loss from internal parts of the
body and retain moisture in subcutaneous tissue
4) Temperature setting
The body will continuously generate heat as a result metabolism of
food that produces energy. This heat will go away especially through
the skin. The three physical processes involved are:
 Radiation (transfer of heat to another object with a lower
temperature and be at a certain distance)
 conduction (transfer of heat to a cooler object in contact with the
body)
 convection, which consists of the movement of warm air molecules
leave the body.
5) Immune response
Recent research results (Niccoloff, 1993) show that some dermal cells
(Langerhans cells, interleukin-1 which produce keratinocytes, and
subgroups of T-lymphocytes) are important components of the
immune system (Sherwood, 2014).

Histology :
1. lymph glands
The lymph nodes consist of a dense mass of lymphocyte aggregates
mixed with wide lymph sinuses containing lymph and supported by a
skeleton of fine reticular fibers. A lymph node is cut in half to reveal

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the cortex on the outside and dark and the medulla on the inside and
light in color. The lymph nodes are surrounded by pericapsular adipose
tissue containing many blood vessels, shown here as arterioles and
venules. A dense connective tissue capsule encloses the lymph nodes.
From the capsule, connective tissue trabeculae are formed which enter
the gland, initially between the lymph nodes, and then branch
throughout the medulla at varying distances. This trabecular
connective tissue also contains the main blood vessels of the lymph
nodes (VP Eroschenko, 2015).

2. Spleen
The spleen is covered by a connective tissue capsule from which it
emerges
connective tissue trabeculae that extend deep into the interior of the
spleen. The main trabeculae enter the spleen at the hilum and extend to
the spleen whole organs. Inside the trabeculae are the trabicularis
arteries and trabecular vein. Trabeculae cut in the plane. The transverse
may appear round or nodular and may contain blood vessel.
The spleen is characterized by numerous aggregates of lymphatic
nodules. These nodules form a white pulp. Lymph nodules too
contains a reduced number of centrum germinativum with aging. Each
lymphatic nodule is passed by vessels blood called the central artery
which is located in the periphery lymphatic nodules. The central artery
is a branch of the trabecularis that become covered with lymphatic
tissue when. These arteries leave the connective tissue trabeculae,
lymph sheath. These periarteries also form lymphatic nodules which
are the white pulp of the spleen (VP Eroschenko, 2015).

3. The thymus gland plays an important role in early childhood in the

development of the immune system. Its main function is to produce a
diverse group of T cells that can respond to the antigen,
undifferentiated lymphocytes are transported from bone marrow via

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 the bloodstream to the thymus gland. in part large thymic cortex,
reticular epithelial cells, also called thymic nurse cells, surrounds
lymphocytes and promotes differentiation, proliferation, and
lymphocyte maturation (VP Eroschenko, 2015).

b. What is the meaning of Mimi, a girl, aged 9 months, was brought by

her mother to the outpatient clinic of RSMP because of a fever and a
red rash appeared on her skin?
Answer:
In this case Mimi had a fever and redness of the skin caused by a
follow-up incident after immunization. The incident was the result of
immunization infection with the measles vaccine from a virus that had
been killed or attenuated. Symptoms of AEFI in the form of fever
more than 37°C fever lasting for 2 days. Rash occurs 1-2 X 24 hours
after immunization and fever lasts for 2-4 days (Ranuh, 2014).
Meaning Fever and rashes that appear on the skin can be caused by
various pathogens, namely viral, rickettsial, bacterial, rickettsial
infections and also possible post-immunization follow-up events
(AEFI) (Halim,2016).
This means that the body temperature does not exceed 40°c. Fever is
a sign that the immune system is trying to fight infection. Red rash
after fever are a symptom of health problems caused by viral infections,
although there are also those caused by bacteria and other pathogens.
Roseola is a viral infection characterized by with a fever for several
days and the appearance of a red rash on the skin.

c. What are the classifications of fever?

Answer:
a. Septic fever
Body temperature gradually rises to very high levels at night and drops
back to above normal levels in the morning. Often accompanied by

11
complaints of chills and sweating. When the high fever drops to a
normal level, it is called hectic fever.

b. Remittent fever
Body temperature can drop every day but never reaches normal body
temperature. The possible causes of recorded temperatures can be as
high as two degrees and not as large as the temperature difference
noted for septic fever.

c. Intermittent fever
Body temperature drops to normal levels for several hours a day . If a
fever like this occurs once every two days, it is called tersiana and if it
occurs two days free of fever between two attacks of fever, it is called
quartana.

d. Continuous fever
Temperature variations throughout the day do not differ by more than
one degree. At a fever level that is continuously very high is called
hyperpyrexia.

e. Cyclic fever
There is an increase in body temperature for several days followed by
several fever-free periods for several days which is then followed by a
rise in temperature to normal.

f. Hectic Fever
In this fever, the body temperature gradually rises to very high levels at
night and drops back to normal levels in the morning. (Nurarif, 2015).

Fevers can be arbitrary classified into acute, sub-acute and chronic

fevers based on duration. Acute fevers (<7 days in duration) are
characteristics ofinfectious diseases such as malaria and viral-related

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 upper respiratory tract infection while sub-acute fevers (usually not
more than 2 weeks in duration) may be seen in cases of typhoid fever
and intra-abdominal abscess, among others. Chronic or persistent
fevers (>2 weeks duration) are typical of chronic bacterial infections
such as tuberculosis, viral infections like HIV, cancers and connective
tissue diseases. However, any cause of acute fever can become
persistent or chronic if untreated (Ogoina, 2011).

d. What are the complications of fever?

Answer:
In general, a fever that is left untreated can cause several
complications such as dehydration, hallucinations, decreased
consciousness, and even convulsions. Fever due to a severe infection
or experienced by people who have a weak immune system
(immunodeficiency), such as people with cancer or HIV, can be
dangerous. It can cause brain and nervous system damage and be life
threatening. Children between the ages of 6 months and 5 years may be
more prone to febrile seizures which usually involve loss of
consciousness and shaking of the limbs on both sides of the body
(Kliegman et al., 2020).

e. What are the classifications of red rash?

Answer:
Diseases with clinical manifestations of skin rashes, apart from
having a wide diagnostic spectrum, also cause a very wide spectrum of
medical emergencies, from mild and harmless to very severe, so they
must be recognized and diagnosed as early as possible. In general,
clinicians perform disease grouping based on the type of disease
rash, rash on the palms, history, and clinical pattern of rash
accompanied by fever.
Examples of diseases:

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1. Maculopapular rash: a group of diseases with a centrally
distributed maculopapular rash, where the rash begins to appear
from the head, neck and then spread throughout the body / spread
to the periphery: generally associated with measles, rubella,
roseola / exanthema subitum or drug-related rash. A group of
diseases with a peripherally distributed maculopapular rash,
which has a predilection for rashes present on the palms of the
hands, soles of the feet, knees and elbows such as
meningococcemia, Rocky Mountain spotted fever, dengue fever,
which initially appears as a maculopapular rash, before turning
into a petechial rash, must be recognized immediately so that
treatment is not too late and fatal.
2. Petechial rash: There are 3 important diseases namely
meningococcemia, Rocky Mountain spotted fever and dengue
fever. This rash is also found in coxsackie virus infection A9,
echovirus 9, cytomegalovirus, atypical measles, viral hemorrhagic
fever caused by both arbovirus and arenavirus. Several bacterial
infections, such as staphylococcemia, disseminated gonococcal
and thrombotic thrombocytopenic purpura, also show the same
symptoms.
3. Erythema rash with desquamation: seen in Scarlet fever, toxic
shock syndrome, scalded skin syndrome caused by
Staphylococcus aureus and Kawasaki syndrome, also frequently
seen in viridan Streptococcus infections, toxic epidermal
necrolysis and graft versus host reactions.
4. Vesicobulous rash – pustules: found in herpes virus infection
varicellazoster also in infection with Staphylococcus bacteria,
gonococcemia. In immunocompromised patients, keep in mind
disseminated herpes simplex virus infection. (Ismoedijanto, 2011)
5. Rashes fall into three general categories: infectious, inflammatory,
and immune system-related.

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  Infectious Rashes – These rashes are most commonly bacterial,
fungal or viral infections.
 Inflammatory Rashes – There are many different types of
inflammation. Acute inflammation comes and goes in a short
period of time, while chronic inflammation stays for a long time.
 Immune system-related Rashes – These rashes appear when the
body’s immune system produces antibodies through the skin.
For example, some antibodies cause a histamine release, which
can result in hives (Sharma et al., 2019).

f. What are the cause of fever and red rash on the skin?
Answer:
- Measles
In measles a maculopapular rash develops with centrifugal spread,
starting from the hairline behind the ears, then spreading to the face,
neck, chest, upper extremities, buttocks, and finally the lower
extremities. This rash can appear for 6-7 days. Fever generally peaks
(up to 400 C) on the 2-3rd day after the appearance of the rash.If the
fever persists after the 3rd or 4th day it generally indicates a
complication (Halim, 2016).
-Chicken pox
Theoretically, the typical varicella rash is described as a multiform
rash that includes a spectrum of papules, vesicles, pustules, to crusts.
The distribution is usually centripetal with the rash starting to appear
on the body and spreading mainly to the upper extremities (Black et al,
2016).
- Erysipelas
The initial skin eruption is in the form of red patches that are getting
wider. Erysipelas skin disorders are erythema, swelling, pain, and
well-defined borders. Other accompanying symptoms can include
fever and malaise (Benson, 2016).

15
g. What are the mechanism of fever and red rash on the skin?
Answer:
Live measles virus enters the body through vaccination --> Virus
migrates to the dermis through blood vessels --> Glycoprotein H in the
virus binds to epithelial cells in the dermis tissue (via the Nectin 4
receptor) and lymphocyte cells in the dermis tissue (via the CD
150/CD receptor SLAM) --> accumulation of infected T cells and
epithelial cells in hair follicles or sebaceous glands via capillaries -->
infection spreads to keratinocytes and causes the virus to spread from
the basal layer to the superficial dermis

Immediately after infection --> non-specific immune system activation

occurs --> phagocytosis of epithelial cells and lymphocyte cells
infected with measles virus --> increased release of proinflammatory
cytokines (IL1, IL6, TNF-a, PGE2) --> PGE2 increases vasodilation
capillary blood vessels in the dermis -> causing a reddish rash on the
skin (maculopapular rash) (Laksono et al, 2019)

Increased production of the proinflammatory cytokine prostaglandin

E2 (PGE2) --> PGE2 crosses the blood-brain barrier --> in the
hypothalamus, PGE2 stimulates the thermoregulatory center -->
hypothalamic set point increases body temperature increases --> fever
(Rota dkk, 2016).

h. What is the connection between fever and red rash on the skin?
Answer:
Fever with a rash is common in children. More than 50 viruses are
known that can cause rashes. Some of the common illnesses caused by
viruses with fever and rash include:
measles, chickenpox, rubella, exanthema subitum. Cause due to
infection bacteria can also occur such as meningogokus (Subnada, et al.
2017).

16
 Fever and red rash on the skin are immune response to antigens that
enter the body from measles immunization that she received 3 days
ago. These include clinical symptoms of measles AEFI. AEFI that
occurs in measles immunization can occur malaise (weakness), fever,
and rash that lasts 7-12 days after immunization and generally lasts for
1-2 days (Ranuh et al, 2017). The skin tissue after getting the vaccine
will give an inflammatory reaction by producing more cytokines which
eventually increase body temperature and vasodilation in the skin
capillaries so that fever and red rash appear on the skin (Laksono et al,
2020).

i. What is the meaning of Fever started 1 day ago and 10 hours later a red
rash appears on the face and body. There are no seizure, cough and
cold?
Answer:
This means that Mimi is not affected by diseases that have seizure,
cough and cold, such as measles, varicella, scarlett, and others. In this
diseases, there are prodromal symptoms first (fever, cough, flu) and
then the appearance of a rash on the skin. Meanwhile, fever and red
rash on the mimi's body are clinical symptoms of adverse events
following immunization (AEFI) after immunization. So MiMI was
exposed to AEFI from measles immunization she got 3 days ago.
AEFI is a medical event related to immunization in the form of
injection reactions, vaccine reactions, pharmacological effects,
procedural errors, coincidences or causal relationships that cannot be
determined (Kemenkes, 2014).
The meaning is fever only 38 c, which if it exceeds 40 c will have a
seizure. Measles lasts approximately 3 days (range 2-4 days), indicated
by fever that can reach 39.50 C ± 1.10 C. In addition to fever,
symptoms may include: malaise, coryza (acute inflammation of the
membranes nasal mucosa), conjunctivitis (eyes) red), and cough. And
in case there are no coughs and colds. This means that there is no

17
 upper respiratory tract disorder and excludes the diagnosis of measles
(Halim, 2016).
The meaning is when fever accompanies a rash in children, it is
usually caused by viral infections. Although viral exanthems are
usually associated with benign, self-limited diseases, in some cas- es
correct diagnosis of an exanthem may be required for prop- er
treatment, monitoring, and initiation of preventive measures for
contacts (Kang, 2015).

j. What is the relationship between age and gender with complaints of

the case?
Answer:
In this case, Mimi received the measles vaccine. Measles vaccine
affects the effectiveness of the measles immunization vaccine given.
The older the toddler is more than 1 year old, the higher the vaccine
efficacy, in accordance with the statement which states that the
measles vaccine efficacy in infants who received the vaccine at the age
of 9 months was 85%, in children who received the measles vaccine at
the age of 12 months it was 95%. and 98% of children aged 15 months.
WHO recommends that the government program the provision of
measles immunization at the age of 9 months where at that age the
vaccine efficacy is low, so that toddlers aged over 1 year will be at risk
of getting measles because protection against the measles virus has not
yet been established perfect and the complaints experienced are not
related to gender (Khotimah, 2015).

2. Previous immunization history, Mimi has received BCG immunization 1

time, Hepatitis B 2 times, DPT 2 times, HiB 2 times and Polio drops 3
times and just received measles immunization 3 days ago.
a. What is the meaning of Previous immunization history, Mimi has
received BCG immunization 1 time, Hepatitis B 2 times, DPT 2 times,

18
HiB 2 times and Polio drops 3 times and just received measles
immunization 3 days ago?
Answer:
because the hepatitis B immunization is not complete, the DPT
immunization is not complete, and the HiB immunization is not
complete. Which is where the provisions of hepatitis B immunization
are 3x, DPT is 3x, HiB is 3x.
This means that Mimi has fulfilled the schedule for giving the
correct immunization program and has the right immunization
schedule. According to IDAI, the BCG immunization schedule is for
infants aged 0-2 months. BCG vaccine which aims to prevent the
occurrence of Tuberculosis disease.
Hepatitis B immunization schedule, namely In the 2017 IDAI
immunization schedule, Hepatitis B (HB) immunization is best given
within 12 hours after birth, while in the 2020 immunization schedule it
should be given immediately after birth to all babies before 24 hours.
DPT immunization schedule, namely the first DPT vaccine is given
no later than 6 weeks of age. DPTw or DPTa vaccines can be given or
in combination with other vaccines. If the DTPa vaccine is given, the
intervals follow the vaccine recommendations, namely at 2, 4, and 6
months of age. In the 2020 immunization schedule, bOPV or IPV is
then given with DPTw or DPTa, IPV (Inactivated Poliovirus Vaccine)
is given at least 2 times before 1 year of age.
Schedule HiB immunization is given from the age of 6 months,
repeated every year. At the age of 6 months to 8 years, the first
immunization is 2 doses with an interval of at least 4 weeks. Age > 9
years, first immunization 1 dose.
Schedule Polio immunization should be given immediately after
birth. If born in a health facility, give bOPV-0 when the baby comes
home or at the first visit. Then give bOPV or IPV with DTwP or
DTaP. The IPV vaccine is given at least 2 times before the age of 1
year with DTwP or DTaP.

19
 Measles immunization schedule, namely In the 2017 immunization
schedule at the age of 9 months, measles immunization is given, while
in the 2020 schedule, rubella (MR) is given (IDAI,2020).

b. How does the body immune system react to BCG, Hepatitites B, DPT,
HiB, Polio and measles immunization?
Answer:
Giving a vaccine is the same as giving an antigen to the body.
Giving antigens either naturally or through vaccination, the body will
react to eliminate these antigens through the immune system.
In the lymph nodes there are T cells, namely T cells that have never
met an antigen. Administration of antigen will cause T cells to
differentiate into effector cells and memory cells. Effector cells will
migrate to sites of infection and eliminate antigens, while memory
cells will be in lymphoid organs which then play a role if the same
antigen is present.
B cells that encounter antigens will differentiate, undergo
transformation, proliferation, and differentiation into plasma cells that
will produce antibodies. Antibodies will neutralize the antigen so that
the ability to infect it disappears. Proliferation and differentiation of B
cells will not only become plasma cells but will also partially become
memory B cells. Memory B cells will be in circulation. When
memory B cells encounter the same antigen, proliferation and
differentiation will occur as before and will produce more antibodies.
The presence of memory cells will facilitate the recognition of
antigens. This means that if someone who has been vaccinated is
infected with the same antigen, it will be easier for the immune system
to recognize the antigen. In addition, more T cells and B cells are
involved and antibody formation is faster and lasts longer.
Synthesis:
In general, the immune system is divided into 2, namely the non-
specific immune system and the specific immune system. The non-

20
 specific immune system is a natural defense mechanism that is innate
and can be directed against various infectious agents or antigens. The
non-specific immune system includes the skin, mucous membranes,
phagocytic cells, complement, lysozyme, interferon, and others. This
immune system is the first line of defense that must be faced by
infectious agents that enter the body. If the non-specific immune
system is unable to eliminate the antigen then the specific immune
system plays a role.
The specific immune system is an adaptive defense mechanism that
is acquired during life and is specifically targeted at one type of
antigen. The specific immune system is played by T cells and B cells.
Defense by T cells is known as cellular immunity while defense by B
cells is known as humoral immunity. Cellular immunity plays a role
against antigens inside cells (intracellular) while humoral immunity
plays a role against antigens outside cells (extracellular). This specific
immune system plays a role in administering vaccines to provide
immunity against one type of infectious agent. This is due to the
memory mechanism in the specific immune system (Sppyan,dkk,2020).

c. What are the types of immunization?

Answer:
1. Active Immunity
Active Immunity results when exposure to a disease organism
triggers the immune system to produce antibodies to that disease.
Active immunity can be acquired through natural immunity or vaccine-
induced immunity.
 Natural immunity is acquired from exposure to the disease
organism through infection with the actual disease.
 Vaccine-induced immunity is acquired through the introduction of
a killed or weakened form of the disease organism through
vaccination.

21
 Either way, if an immune person comes into contact with that
disease in the future, their immune system will recognize it and
immediately produce the antibodies needed to fight it. Active
immunity is long-lasting, and sometimes life-long.
Active immunity occurs when exposure to a disease organism
triggers the immune system to produce antibodies against that disease.
Active immunity can be acquired through natural immunity or vaccine-
induced immunity.

2. Passive Immunity
Passive immunity is provided when a person is given antibodies to a
disease rather than producing them through his or her own immune
system.
 Immunization with live attenuated pathogens (Live at tenuated) -->
introduces attenuated pathogens into the body. The attenuated
pathogen mimics the type of protective immunity induced in a
person given the vaccine. Example: attenuated virus --> smallpox,
yellow fever, measles, mumps, rubella, and chicken pox. Examples
of attenuated bacteria --> BCG, oral typhoid. The advantages of
vaccines with live attenuated pathogens --> provide immunity that
lasts for decades, even with a single dose.

 subunit immunization / part of the microorganism/ inactivated

(bacteria, virus or its components are inactivated) --> hepatitis B
vaccine, tetanus toxoid, diphtheria, pneumococcal vaccination,
Haemophilus Influenzae type B or meningococcus vaccination
(Pollard & Bijker, 2021).

The type of immune system in this case is Adaptive Immunity

The development of adaptive immunity is aided by the actions of the
innate immune system, and is critical when innate immunity is
ineffective in eliminating infectious agents. The primary functions of

22
 the adaptive immune response are: the recognition of specific “non-
self” antigens, distinguishing them from “self” antigens; the generation
of pathogen-specific immunologic effector pathways that eliminate
specific pathogens or pathogen-infected cells; and the development of
an immunologic memory that can quickly eliminate a specific
pathogen should subsequent infections occur. The cells of the adaptive
immune system include: antigen-specific T cells, which are activated
to proliferate through the action of APCs, and B cells which
differentiate into plasma cells to produce antibodies (Marshall, et al.,
2018)

d. What are the procedure for BCG, Hepatitites B, DPT, HiB, Polio and
measles immunization?
Answer:
1. BCG Vaccine
The BCG vaccine is a freeze-dried vaccine containing live
attenuated Mycobacterium bovis (Bacillus Calmette Guerin), a
strain of paris. Given at the age of 0-1 months.
How to present and dosage:
• Dosage: 0.05 ml, 1 time.
• Injected intracutaneously in the area of the right upper arm
(insertio musculus deltoid), using ADS 0.05 ml.

2. Hepatitis B Vaccine
Recombinant virus vaccine that has been inactivated and is non-
infectious, derived from HBsAg. Used for prevention against
hepatitis B.
Method of present and dosage:
• Dose of 0.5 ml or 1 (piece) of HB PID, intramuscularly, preferably
in the anterolateral thigh.
• Given for 3 doses.

23
 • The first dose at 0–7 days of age, subsequent doses at a minimum
interval of 4 weeks (1 month).

3. DTP-Hib Vaccine
Used for the prevention of diphtheria, tetanus, pertussis (whooping
cough), and Haemophilus influenzae type b infection simultaneously.
Method of present and dosage:
• The vaccine should be injected intramuscularly in the anterolateral
upper thigh.
• One pediatric dose is 0.5 ml.

4. Oral Polio Vaccine (OPV)

Trivalent Polio Vaccine consisting of an attenuated suspension of
poliomyelitis virus types 1, 2, and 3 (Sabin strain).
Method of present and dosage:
Orally (by mouth), 1 dose (two drops) 4 times (dose) of present,
with an interval of each dose of at least 4 weeks.

5, Measles Vaccine
Live attenuated virus vaccine.
Method of present and dosage: 0.5 ml is injected subcutaneously in
the left upper arm or anterolateral thigh, at the age of 9–11 months.
(Kemenkes, 2014).

e. How long is the protective effect of BCG, Hepatitites B, DPT, HiB,

Polio and measles immunization?
Answer:
1. BCG : long-lasting effect.
BCG vaccination shows long-term effects on innate trained
immunity. This is revealed by the persistent increase in LPS-mediated
proinflammatory cytokine production, and expression of pattern

24
recognition receptors and monocyte activation markers (Kleinnijenhuis
et al., 2014).
2. Hepatitis B
Studies indicate that immunologic memory remains intact for at
least 30 years among healthy people who initiated hepatitis B
vaccination at >6 months of age. The vaccine confers long-term
protection against clinical illness and chronic hepatitis B virus
infection. Cellular immunity appears to persist even though antibody
levels might become low or decline below detectable levels. Among
vaccinated cohorts who initiated hepatitis B vaccination at birth, long-
term follow-up studies are ongoing to determine the duration of
vaccine-induced immunity (Bruce et al., 2016).
3. DPT
The results of clinical trials evaluating the duration of protection
conferred by DTaP vaccines after three or four doses suggested that
protection against pertussis was sustained 5 to 6 years after vaccination
(Klein et al., 2012).
4. HiB
The vaccine provides long-term protection from Haemophilus
influenzae type b. Those who are immunized have protection against
Hib meningitis; pneumonia; pericarditis (an infection of the membrane
covering the heart); and infections of the blood, bones, and joints
caused by the bacteria (Hammit et al., 2016).
5. Polio
Protection against poliovirus remained elevated 6 and 11 months
after an IPV boost, although at a lower level than reported at 1 month.
Protective antibodies against all three viruses persisted for at least up
to 18 years after administration of the last OPV dose, with PV1 and
PV2 antibodies detected in > 95% of the participants > 30 years after
the last OPV dose (Bianchi, 2021).
6. Measles

25
 Protection against measles, mumps and rubella starts to develop
around 2 weeks after having the vaccine. Booster is given at 5-7 years
old (Centers for Disease Control and Prevention, 2019).

f. What are the ways to get immunity of the body?

Answer:
Immunity to a disease is achieved through the presence
of antibodies to that disease in a person’s system. There are two types
of immunity: active and passive.
1. Active Immunity
Active Immunity results when exposure to a disease organism
triggers the immune system to produce antibodies to that disease.
Active immunity can be acquired through natural immunity or
vaccine-induced immunity.
- Natural immunity is acquired from exposure to the disease
organism through infection with the actual disease.
- Vaccine-induced immunity is acquired through the introduction of
a killed or weakened form of the disease organism through
vaccination.
Either way, if an immune person comes into contact with that
disease in the future, their immune system will recognize it and
immediately produce the antibodies needed to fight it. Active
immunity is long-lasting, and sometimes life-long.
2. Passive Immunity
Passive immunity is provided when a person is given antibodies
to a disease rather than producing them through his or her own
immune system.
- A newborn baby acquires passive immunity from its mother
through the placenta.
- People can also get passive immunity through antibody-containing
blood products such as immune globulin, which may be given
when immediate protection from a specific disease is needed.

26
 The major advantage to passive immunity is that protection is
immediate, whereas active immunity takes time (usually several
weeks) to develop. However, passive immunity lasts only for a few
weeks or months. Only active immunity is long-lasting (CDC,2021).

g. What are the requirements for giving immunizations to children?

Answer:
Children who will receive immunizations must be in good health (no
cough, runny nose, fever, etc.) because in principle immunization is
giving a virus by introducing viruses, bacteria, or parts of bacteria into
the body, and then producing antibodies (immunity). To form a high
immunity, the child must be in a fit condition. If the child is sick, the
immunity that is formed is not good.
Immunization should not be given only under certain conditions, for
example the child has an abnormality or decreased immunity, such as
poor nutrition or HIV/AIDS or in the use of steroid drugs, the child is
known to have a severe allergic reaction to it. certain immunizations or
certain immunization components (Marimbi, 2010).

h. What is the purpose of BCG, Hepatitites B, DPT, HiB, Polio and

measles immunization in the case?
Answer:
1. The BCG vaccine aims to reduce the risk of severe tuberculosis and
primary tuberculosis.
2. The hepatitis B vaccine aims to gain immunity against hepatitis B
disease.
3. Polio vaccine aims to build immunity against polio.
4. HiB vaccine to prevent infection with Haemophilus influenza type b.
5. DPT vaccine is used for prevention against diphtheria, pertussis,
tetanus.
6. There is also a combined exercise called Pentavalent Immunization
(DPT-HB-Hib). The function of this is to simultaneously prevent

27
 diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus
influenzae infection (Ranuh et al, 2017).
7. Measles vaccine is given to provide active immunity against
measles. Measles immunization for toddlers is very important
because the measles vaccine has an efficacy of approximately 85%,
so that if there are children who do not have immunity to measles,
they will be a group that is susceptible to measles (Kemenkes, 2014).

i. What is the connection between the vaccines she has received and her
fever and reddish rash?
Answer:
The meaning of the sentence above is the fever and red rash
experienced due to side effects of the vaccine. The side effects of this
vaccination are known as post-immunization co-occurrence (AEFI),
which occur quickly or slowly and can be divided into local, systemic,
nervous system reactions, and other reactions. Local reactions are
characterized by pain and redness at the injection site, as well as fever
or red rash (Sumarni, 2019).

j. What is the immunization schedule of children from 0-18 years old

based on IDAI?
Answer:

28
 The blue color indicates the primary dose, the yellow color indicates
that if there is a vaccine left behind, it can be followed up with that
time interval, the pink color indicates the booster vaccine, the orange
color indicates the vaccine before it comes to endemic areas (Ikatan
Dokter Anak Indonesia, 2020).
For the measles vaccine, the following is the explanation:
Measles immunization is immunization given to induce active
immunity against measles (morbili/measles). The frequency of giving
measles immunization is once at the age of 9 months, and it is
recommended to give it according to schedule. Apart from the fact that
antibodies from the mother have decreased at the age of 9 months,
measles generally attacks children under five. If by 12 months the
child has not received measles immunization, then at the age of 12
months the child must be immunized with MMR (Measles Mumps
Rubella). Measles immunization is administered subcutaneously.
Usually there is a reaction due to immunization. There may be a low-
grade fever and there may be redness/red patches on the cheeks under
the ears on 7-8 days after injection. Measles, not given if the baby is
suddenly sick and has high fever (Hartaty, 2017).

k. What are the indication and contraindication immuzation for children?

Answer:

29
 Indications for the provision of active immunity against measles.
Contraindications Individuals with immunodeficiency disease or
individuals suspected of having impaired immune response due to
leukaemia, lymphoma (Yudhianti, 2020).

l. What are the types of immune systems?

Answer:
1. Nonspecific Immune System
This system is the first line of defense against attacks by various
microbes that can provide an immediate and rapid response. Called
non-specific because it is not directed against a particular microbe, and
has been present and ready to function since birth. The components of
the nonspecific immune system are passed from parent to child and are
directed against molecules that are expressed only by microorganisms.
Physiological nonspecific immunity is a normal component of the
body, always found, in healthy individuals, ready to prevent microbes
from entering the body and quickly get rid of them.

2. Specific Immune System

In contrast to the nonspecific immune system, the specific immune
system has the ability to attack objects that are considered foreign to
itself. Foreign bodies that are first exposed to the body are immediately
recognized by the specific immune system. The exposure causes
sensitization, so that the same antigen entering the body a second time
will be recognized more quickly and then destroyed. Therefore, the
system is called specific. To destroy foreign objects that are harmful to
the body, the specific immune system can work without the help of the
non-specific immune system. The specific immune system consists of
the humoral and cellular systems. In humoral immunity, B cells release
antibodies to eliminate extracellular microbes. In cellular immunity, T
cells activate macrophages as effectors to destroy microbes or activate

30
 CTL cells as effectors that destroy infected cells (Baratawidjaja &
Rengganis. K, 2018).

m. What is the impact if the children is not fully vaccinated?

Answer:
If the child is not fully immunized, it will result in as follows:
1. Disease Will Easily Attack.
Of course, if your child only gets the necessary immunizations such
as DTP and Hib, it doesn't mean that your child will be immune to
infectious diseases in general. Dangerous disease such as Hepatitis A,
Hepatitis B, Measles, and even Polio will be very easy and risky to
attack your child. In other words, for matters of disease above your
child's immunity is the same as the immunity of children who are not
immunized (IDAI, 2014).
2. Easily infected with sick people.
It is certain that your child will be susceptible to dangerous
infectious diseases such as polio if in your child's body there is no
defense system that fully protects it. It doesn't matter if it comes from
the bacteria itself or even from the results of transmission
3. There are Side Effects.
The vaccine is deliberately given in stages because it follows the
ability of your baby to receive the vaccine. Well there are some early
vaccines whose nature is safe for a certain period of time after which it
will cause side effects. That's why there are forms of Vaccine-2,
Vaccine-3, Vaccine-4 and so on, because apart from extending the life
of the vaccine, it is also useful for eliminating the effects side of
existing vaccines. And this is one The danger is if your child is not
given complete immunizations, which parents often don't know about
(IDAI, 2014).

n. What are the effect that can be caused after immunization?

Answer:

31
Adverse Events Following Immunization (AEFI)
The effect that can be caused after immunization is KIPI or Adverse
Events Following Immunization (AEFI), Symptoms of AEFI caused
by vaccine induction can generally be predicted in advance because
they are intermittent reactions and are clinically usually mild. However,
severe clinical symptoms such as systemic anaphylactic reactions with
a risk of death can occur.
1. Local Reaction
Pain at the injection site, redness at the injection site, swelling at
the injection site for DPT and tetanus, BCG scar occurs at least 2
weeks later ulceration and heals after several months.
2. Systemic reaction
Fever, except DPT, irritability, malaise, symptoms systemic. In
MMR and measles, systemic reactions are caused by infection
vaccine viruses. Fever and/or rash, conjunctivitis, and milder than
measles infection, but severe in cases immunodeficiency. In
Mumps there is swelling of the parotid gland, In rubella there is
joint pain and swollen lymph nodes. On Oral Polio Vaccine
(OPV) diarrhea, dizziness, and muscle aches.
3. Vaccine reaction heavy
Seizures, thrombocytopenia, hypotonic hyporesponsive episode
(HHE), persistent inconsolable srceaming is self-immitting and
does not is a long-term problem, anaphylaxis, potentially fatal but
can be cured without long term effects. Encephalopathy due to
measles or DTP immunization (Kemenkes, 2014).
Especially, the effect of measles vaccine, patients may develop a
low-grade fever and redness for 3 days which can occur 8–12 days
after vaccination.
The side effects that do occur are usually mild and may include:
 Soreness, redness, or swelling where the shot was given
 Fever
 Mild rash

32
  Temporary pain and stiffness in the joints
More serious side effects are rare. These may include high fever that
could cause a seizure (Strebel et al., 2013).

o. What are the mandatory immunization for children?

Answer:
Immunization scheduling is based on the recommendation of the
Indonesian Pediatrician Association (IDAI) for children aged 0-18
years. Making rules for immunization scheduling recommendations for
IDAI 2017 using the forward chaining method. Forward Chaining is a
technique of gathering information (facts) and then drawing
conclusions. Forward chain method Immunization that must be given
is an immunization that has become a global commitment, meaning
that it must be given by all countries in the mandatory immunization is
Hepatitis b, polio, BCG, DTP, HiB, PCV, rotavirus, influenza, MR, JE,
varisela, hepatitis A, tifoid,HPV, dengue (Kemenkes, 2014).

p. What is the meaning of KIPI?

Answer:
Adverse Events Following Immunization are medical events that
occur after immunization can be in the form of vaccine reactions,
injection reactions, procedural errors, or coincidences until a causal
relationship is determined (Hadinegoro, 2016).

q. What are the classification of KIPI?

Answer:
1. Vaccine induced. The occurrence of AEFI is caused by the
intrinsic factor of the vaccine against the individual recipient. For
example, a child developed poliomyelitis after receiving the oral
polio vaccine.
2. Vaccine potentiated. Clinical symptoms that arise can occur at any
time, when this occurs because of vaccine provocation. Example:

33
 Post-immunization febrile seizures that occur in children who
have a predisposition to seizures.
3. Programmatic errors. Symptoms of AEFIs arise as a result of
errors in vaccine manufacturing and procurement techniques or
administration techniques. Example: induration occurs at the
injection site because the vaccine that should be given
intramuscularly is given subcutaneously.
4. coincidental. AEFI occurs at the same time as symptoms of other
illnesses that are being suffered. Example: Babies who suffer from
congenital heart disease suddenly cyanosis after being immunized
(World Health Organization, 2014).

AEFIs are grouped into 5 categories:

1) Reactions related to vaccine products
AEFI caused or triggered by one or more components contained
in the vaccine product
2) Reactions related to vaccine quality defects
AEFIs caused by one or more vaccine quality defects, including
vaccine delivery kits provided by the manufacturer
3) Reactions related to incorrect immunization procedures
AEFIs caused by inadequate vaccine handling, prescribing or
administration of vaccines that could have been avoided
4) Immunization-related anxiety reactions
This AEFI occurs because of anxiety at the time of immunization
5) Incidents.
This AEFI is caused by things other than vaccine products,
immunization errors or anxiety due to immunization (WHO,
2020).

r. What are the types of vaccines in the case?

Answer:

34
 There are two types of vaccines, namely Live Attenuated and
Inactivated. The BCG vaccine, polio vaccine, and measles vaccine
include Live Attenuated vaccines. A polio vaccine is also include in
inactivated intact. Meanwhile, Hepatitites B vaccine, DPT vaccine and
HiB vaccine are fractionally inactivated vaccine types (fractionally
obtaned from the organisms taken, they are produced by growing
bacteria or viruses on culture media, then inactivated. Usually, only
partially).The measles vaccine is a live attenuated virus vaccine
injected subcutaneously in the left upper arm or anterolateral thigh, at
9–11 months of age (Kemenkes, 2014).

s. What are the factors that cause a vaccine to fail?

Answer:
The fail of immunization depends on several factors:
a. Giving time
Vaccines given when children still have high levels of antibodies
from their mothers will give unsatisfactory results.
b. Immunological maturity
Infants do not yet have mature immune function so that they will
give less effective results than in children. Individuals with low
immune status, such as patients receiving immunosuppressant
treatment or currently experiencing infection, will affect the success
of immunization.
c. Nutritional state
Lack of nutrition causes the ability of the immune system to be
weak. Although the level of immunoglobulin is normal or elevated,
it is unable to bind to antigens properly due to a lack of amino acids
needed for antibody formation
d. How to give the vaccine
The way of giving gives the response that arises. Oral vaccine (by
mouth) will cause local and systemic immunity. Meanwhile,
parenteral vaccine (injected) only provides systemic immunity

35
 e. Vaccine dose
Too little dose will cause less immune response. Doses that are too
high will also inhibit the expected immune system
f. Frequency of administration
The administration distance is too close, when antibody levels are
still high, the incoming antigen is immediately neutralized by the
antibody so that it does not have time to stimulate the immune
system (Hartaty, 2017).

t. What are the differences between vaccination and immunization?

Answer:
Vaccination is the process of giving vaccines by injection or
dripping into the mouth to increase the production of antibodies to
ward off certain diseases (Iskak, et al, 2021).
Immunization is an effort to actively generate/increase a person's
immunity to a disease, so that if one day they are exposed to the
disease, they will not get sick or only experience mild illness
(Kementerian Kesehatan Republik Indonesia, 2014).
So, there is no difference between vaccination and immunization,
because both are processes to increase a person's immunity through
vaccines, for the vaccine itself is :
Vaccines are antigens in the form of dead microorganisms, still alive
but attenuated, still intact or parts thereof, which have been processed,
in the form of microorganism toxins that have been processed into
toxoids, recombinant proteins which when given to a person will cause
active specific immunity against certain infectious diseases
(Kementerian Kesehatan Republik Indonesia, 2014).
Immunization is an effort to provide immunity to infants and
children by introducing vaccines into the body to make antibodies to
prevent certain diseases. Vaccines are substances used to stimulate the
formation of antibodies that are introduced into the body by injection
(Kemenkes,2014). So the main point of difference between

36
 immunization and vaccines is that immunization is an effort to provide
immunity for our body meanwhile vaccines are materials used that
will enter our body.

u. How to store vaccine properly?

Answer:
1. Stored at a temperature of 2 to 8 for BCG, Measles,DPT, and
others. -2 for Polio vaccine.
2. The bottom of the refrigerator is placed cool pack as a cold barrier
and temperature stability.
3. Placement of vaccine boxes has a distance of at least 1-2 cm or
one fingers.
4. BCG, Measles, Polio vaccines are placed close to the evaporator.
5. DPT, TT, DT, Hepatitis B, DPT vaccines are placed far away
from evaporators.
6. Vaccine in the refrigerator should be placed in the vaccine box
(IDAI, 2014).

3. Physical examination:
General Condition: Compost mentis, BW: 9 kg, BH: 75cm
Vital Signs: pulse 110 x/menit, RR: 28 x/menit, Temp: 38oC
Head : Pale conjunctiva (-/-), rinorea (-).
Chest:
• Lung : within normal limits
• Heart : Normal first and second heart sounds, no murmurs
Abdomen: liver and spleen are not palpable
Extremities: within normal limits
Dermatological status: macular erythematous papules appear discrete on the
face and body

a. How is the interpretation of the physical examination?

Answer:

37
 Physical examination In the case Interpretation
General condition Compos mentis Normal
BW 9 kg Normal
BH 75 cm Normal
Pulse 110 x/menit Normal
RR 28 x/menit Normal
Temp 38 oC Abnormal (febris)
Lung Within normal limits Normal
Heart Normal first & second Normal
heart sound
Abdomen Liver & spleen are not Normal
probable
Extremities Within normal limits Normal
Dermatological Macular erythematous Abnormal (red rash)
papules appear discrete
on the face & body

b. What is the abnormal mechanism of the physical examination?

Answer:
Live measles virus enters the body through vaccination --> Virus
migrates to the dermis through blood vessels --> Glycoprotein H in the
virus binds to epithelial cells in the dermis tissue (via the Nectin 4
receptor) and lymphocyte cells in the dermis tissue (via the CD
150/CD receptor SLAM) --> accumulation of infected T cells and
epithelial cells in hair follicles or sebaceous glands via capillaries -->
infection spreads to keratinocytes and causes the virus to spread from
the basal layer to the superficial dermis

Immediately after infection --> non-specific immune system activation

occurs --> phagocytosis of epithelial cells and lymphocyte cells
infected with measles virus --> increased release of proinflammatory
cytokines (IL1, IL6, TNF-a, PGE2) --> PGE2 increases vasodilation

38
 capillary blood vessels in the dermis -> causing a reddish rash on the
skin (maculopapular rash) (Laksono et al, 2019)

Increased production of the proinflammatory cytokine prostaglandin

E2 (PGE2) --> PGE2 crosses the blood-brain barrier --> in the
hypothalamus, PGE2 stimulates the thermoregulatory center -->
hypothalamic set point increases body temperature increases --> fever
(Rota dkk, 2016).

4. How to diagnose the case?

Answer:
1. Anamnesis:
Mimi, a girl, aged 9 months, was brought by her mother to the outpatient
clinic of RSMP because of a fever and a red rash appeared on her skin.
Fever started 1 day ago and 10 hours later a red rash appears on the face
and body. There are no seizure, cough and cold.
2.Immunization history:
BCG immunization 1 time, Hepatitis B 2 times, DPT 2 times, HiB 2
times and Polio drops 3 times and just received measles immunization 3
days ago.

3. Physical Examination:
General Condition: Compost mentis, BW: 9 kg, BH: 75cm
Vital Signs: pulse 110 x/menit, RR: 28 x/menit, Temp: 38 C
Head : Pale conjunctiva (-/-), rinorea (-).
Chest:
• Lung : within normal limits
• Heart : Normal first and second heart sounds, no murmurs
Abdomen: liver and spleen are not palpable
Extremities: within normal limits
Dermatological status: macular erythematous papules appear discrete on
the face and body

39
5. How is the differential diagnosis in the case?
Answer:
1.Adverse events after measles immunization
2.Measles/measles infection

6. How is the supporting examination in this case?

Answer:
Blood tests in the form of leukopenia and lymphacytynia Measles
immunoglobulin M (IgM) examination can also help diagnose and usually
can be detected since the first and second day after rash appears
(Maldonando, 2012).

7. How is the working diagnosis in the case?

Answer:
Mild measles AEFI (Adverse Events After Immunization).

8. How is the management in this case?

Answer:
For cases can recover spontaneously, but if there are symptoms can be
given a drug related symptomatic.

symptomatic management of cases

Symptomatic pharmacological therapy:
• PCT syrup (given 3-4 times a day) -->fever, pain (Herve dkk, 2019)

Non-pharmacological therapy:
• Give breast milk / formula as usual (more often and more)
• Sweat-absorbent and thin clothes

9. What are the complications in the case?

Answer:

40
 •Bronkopneumonia
•Kejang demam
•Ensefalitis
•SSPE (subacute Sclerosing Panencephalitis)
•Otitis media
•Enteritis
(Misin dkk, 2020)

10. What is the prognosis in the case?

Answer:
Quo ad vitam: bonam
Quo ad functionam: bonam
Quo ad sanationam: bonam

11. How is the SKDI in the case?

Answer:
Ability level 4A, namely diagnosing, managing independently and
thoroughly. Doctor graduates are able to make clinical diagnoses and carry
out management of the disease independently and thoroughly.
Competencies achieved at the time of graduation from a doctor
12. NNI
a. Q.S. An-Nisa: 71

The translation:
O you who believe! Be prepared, and advance (to the battlefield) in
groups, or advance together (in unison)

Interpretation: By vaccinating, it means that we as Muslims have taken

precautions in dealing with several infectious diseases so that when

41
 exposed they do not feel severe symptoms because the body has stored
the memory of the disease through vaccines.

b. Q.S. Al-Baqarah: 195

The translation:
(195) And spend (your wealth) in the way of Allah, and do not
throw (yourself) into destruction with your own hands, and do good.
Indeed, Allah loves those who do good.

Interpretation: the relationship related to the case, namely so that the

soul (an-nafs) is guaranteed safety and security and is protected from
something dangerous that causes death, then one should not take an
action or approach something that causes destruction. And Allah loves
those who do good to others.

42
2.7 Conclusion
Mimi, a 9 month old baby, has a fever, red rash, and discrete macular
erythematous papules on the face and body because of the mild AEFI reaction
after receiving measles immunization.

2.8 Conceptual Framework

Measles immunization ( live attenuated

virus) by subcutanedus

Anti gen enters the body

Immune response

Produce cytokines (IL-1, IL-6,

TN- α, FN- α

Production CFPGE 2 in skin capillary vasodilation

hipotalamus

increased thermostat

red rash and discrete

macular erythematous
Fever

Mild reaction measles

AEFI

43
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ATTACHMENT

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