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    Clinical Case Analysis: Tarlac State University College of Science

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    Krisianne Mae Lorenzo Francisco
    Pio Rodriguez, a 19-year-old male, has been diagnosed with rheumatic heart disease. As a child, he often had sore throats and loved sweets but his condition was left untreated. He later experienced rheumatic fever attacks characterized by fever and knee arthritis. Multiple valve replacement surgeries were needed due to damage to his heart valves. His current treatment plan includes medications like Digoxin and injections of Benzathine penicillin to prevent future streptococcal infections from worsening his condition.

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    Clinical Case Analysis: Tarlac State University College of Science

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    175 views3 pages
    Pio Rodriguez, a 19-year-old male, has been diagnosed with rheumatic heart disease. As a child, he often had sore throats and loved sweets but his condition was left untreated. He later experienced rheumatic fever attacks characterized by fever and knee arthritis. Multiple valve replacement surgeries were needed due to damage to his heart valves. His current treatment plan includes medications like Digoxin and injections of Benzathine penicillin to prevent future streptococcal infections from worsening his condition.

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    rheumatic heart disease case analysis pathophysiology

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    Case Analysis

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    Pio Rodriguez, a 19-year-old male, has been diagnosed with rheumatic heart disease. As a child, he often had sore throats and loved sweets but his condition was left untreated. He later experienced rheumatic fever attacks characterized by fever and knee arthritis. Multiple valve replacement surgeries were needed due to damage to his heart valves. His current treatment plan includes medications like Digoxin and injections of Benzathine penicillin to prevent future streptococcal infections from worsening his condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    175 views3 pages

    Clinical Case Analysis: Tarlac State University College of Science

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    Pio Rodriguez, a 19-year-old male, has been diagnosed with rheumatic heart disease. As a child, he often had sore throats and loved sweets but his condition was left untreated. He later experienced rheumatic fever attacks characterized by fever and knee arthritis. Multiple valve replacement surgeries were needed due to damage to his heart valves. His current treatment plan includes medications like Digoxin and injections of Benzathine penicillin to prevent future streptococcal infections from worsening his condition.

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    © All Rights Reserved
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    TARLAC STATE UNIVERSITY

    COLLEGE OF SCIENCE
    DEPARTMENT OF NURSING
    Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

    CLINICAL CASE ANALYSIS

    Name of Patient Pio Rodriguez Age: 19 yrs old Gender: Male


    Address Brgy. San Fernando, Victoria, Tarlac Date Admitted: January 30,
    2021
    Diagnosis Rheumatic Heart Disease

    NURSING HISTORY:
    According to his mother, Pio loved to eat sweets such as candy and chocolate. He often
    complaint for sore throat. Her mother did not become attentive to this condition because she
    thought it was only a common childhood illness that might pass even when left untreated. On
    July 29, 2010, Pio was 7 years old, he started to experience rheumatic attacks characterized by
    fever and arthritis of the knee.

    On September 18, 2017 he had paroxysmal palpitations. Therefore November 24, 2018 they
    consulted in Loving Mother Diagnostic Center for further examination. The ECG revealed
    severe left ventricular hypertrophy while the chest radiograph revealed cardiomegaly and the
    patient were diagnosed of double aortic lesion and rheumatic disease and he started to undergo
    multiple valve replacement surgeries.

    On February 21, 2020 he experienced dyspnea on moderate exertion and palpitations became
    more frequent.

    January 30, 2021 during his consultation in Loving Mother Diagnostic Center, his vital signs
    were as follows: Body Temperature 36.6 ⁰C, Blood Pressure left arm 100/80 mmHg, aortic pulse
    rate 118 bpm. Cardiac auscultation revealed systolic murmur in the aortic are and diastolic
    murmur in the left sterna border. Presence of a third heart sound was noted.
    PATHOPHYSIOLOGY:

    Modifiable factor/s: Non modifiable factor/s:

     Insufficient medical access and  Age


    nutrition.
     Untreated streptococcal infection.

    Group A beta – hemolytic streptococcus


    (Sore throat)

    Activation of the immune response of the body


    (Fever)

    Benzathine
    penicillin Increase production of antigen

    Antigen circulates to the


    body system

    Antigen circulates to the


    Bind to receptors in the body system
    synovial joints.

    Autoimmune response attack the heart valves


    Molecular mimicry of
    antibodies occur
    Inflammation of the layers of the heart
    (Left ventricular hypertrophy, Cardiomegaly)
    Inflammation
    (Arthritis of the knee)
    Difficulty of heart to pump
    (dyspnea and palpitation)
    Digoxin
    Scarring of the heart valves that damage
    aortic valve
    (Valve replacement surgery)

    Rheumatic Heart Disease


    DIAGNOSTIC PROCEDURES:

     Electrocardiogram: revealed left ventricular


     Chest Radiograph: revealed cardiomegaly
     WBC: (4.5 – 10.5 x 109 /L) 20.5 increased WBC

    MEDICAL MANAGEMENT:

     Digoxin (0.25 mg daily)


     Benzathine penicillin 1.2 unit IM every 2 weeks
     Surgical treatment of the aortic valve was precribed

    Name of Student:
    Date Submitted: C.I.’s Signature

    Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

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