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