Grand Case Study V7 Final 030310
Grand Case Study V7 Final 030310
Grand Case Study V7 Final 030310
I. General Objective
This study aims to present the case of a patient diagnosed with Kawasaki
Disease and highlight the nursing management associated with the medical care
provided to a patient with such a disease.
INTRODUCTION
1
I. Definition and History
2
II. Possible Risk Factors
3
3. Rubella
4. Meningococcal septicemia
5. Klebsiella pneumoniae bacteremia
6. Coxiella burnettie
7. Human lymphotropic virus infection
The following signs and symptoms are present in the disease during its
stages:
Acute Stage (Days 1 to 11)
High fever
Irritability
Bilateral conjunctivitis
Rashes
Strawberry tongue and lip fissures (cracks)
Unilateral lymphadenitis
Mild hepatic dysfunction
4
Myocarditis, pericarditis, mitral valve regurgitation, and depressed
myocardial functioning can be recorded by electrocardiogram
6
PATIENT PROFILE
I. Demographic Data
Name: Patient CDC
Age: 1.5 years old
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Address: Blk15 Lot 10, Our Mahogany 1 Village, Pulo, Cabuyao,Laguna
Birthday: July 10, 2008
Birth Place: San Pablo City, Laguna
Religion: Roman Catholic
Sex: F
Nationality: Filipino
Mother’s Name: Roselia Age: 33 y/o Occupation: Employee (Human Resources)
Father’s Name: Dante Age: 38y/o Occupation: Employee (Quality Control)
V. Nutritional History
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Patient CDC was breastfed for the first 2 weeks after birth. A milk formula
was given from 2 weeks after birth to present. Ratio of formula is 1:1 milk to
water given 6 ounces every 2 hours.
Patient started eating cereals, meat, fruits, fish, and vegetables on the
sixth (6th) month. Twenty-four (24) hours prior to confinement, patient ate bread
and milk for breakfast, and rice and soup for lunch and dinner.
Patient is given Celine for vitamins.
Patient has no known food allergies.
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PHYSICAL ASSESSMENT
Sex: Female
I. General Survey
Received patient lying on bed, awake and responsive, not in any respiratory distress. With IVF of
0.9% NaCl 1000cc at right arm KVO. The patient measures 81cm in height and weighs 11.5kg. Patient appears to
be restless and irritable as evidenced by increased movement and uncontrollable crying. Patient does not appear
to be in respiratory distress.
Patient has temperature of 38.4°C, axillary with cardiac rate of 121 beats per minute, regular respiratory rate
of 32 breaths per minute, and blood pressure of 90/60 mmHg.
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PART TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
Skin Inspection Color varies from light to Erythematous and Presence of
and deep brown maculopapular rashes erythematous and
Palpation are present on the back, maculopapular rashes
abdomen, chest, and is one criteria in
extremities diagnosis of Kawasaki
Disease
No edema Hands and feet are Changes in the
reddish, edematous, peripheral extremities
shiny, and dry-looking such as edema and
desquamation are
criteria for diagnosing
Kawasaki Disease
Moisture in skin folds and Skin is moist especially on Changes in the
axillae areas with folds; presence peripheral extremities
of desquamation on such as edema and
fingers, toes, and labial desquamation are
area criteria for diagnosing
Kawasaki Disease
Skin temperature is Skin temperature is Temperature of 38.4°C
uniform within normal uniformly warm due to upon assessment;
range elevated body persistent fever for at
temperature least 5 days is the
earliest sign of
Kawasaki Disease
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Head Inspection Configuration is Head is normocephalic in Normal
and normocephalic shape
Palpation No lesions or tenderness Absence of lesions and no Normal
signs of tenderness
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Anterior and posterior Anterior and posterior Normal
fontanels are flat and fontanels appear to be flat
closed and closed
Hair Inspection Evenly distributed, thick Hair is thick, smooth, Normal
hair, silky, resilient, no moist, and with no signs of
infestation parasitic infestation
Eyes:
Sclera Inspection Appears white Sclera is slightly reddish Bilateral non-purulent
conjunctival injection
is one of the signs of
Kawasaki Disease
Eye Balls Inspection Eyeballs are symmetrical Eyeballs are symmetrical Normal
in size in shape and size
Not protruding There is no protrusion
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
13
Palpebral Inspection Smooth, pink or red Bulbar conjunctiva are Bilateral conjunctival
and Bulbar slightly reddish in color injection is one of the
Conjuctiva criteria in diagnosing
Kawasaki Disease
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Ears Inspecton Auricles fair in color Auricles are fair in color, Normal
and Symmetrical and aligned symmetrical in shape,
Palpation with outer canthus of eyes flexible with no tenderness
Auricles are flexible, firm, There is no discharge from Normal
no tenderness the ear canal
Absence of purulent Responds to the voice of Normal
discharge in the external mother and father
canal
Patient responds to sound
Nose Inspection Nares are patent Patent nares with septum Normal
and Septum on the midline on the midline
Palpation Mucosa is pinkish in color Mucosa is pinkish Normal
Mouth Inspection Lips are moist and pinkish Lips are red in color, dry, Changes in the mouth
and in color and cracked and oral mucosa are
Palpation Oral mucosa is pinkish Oral mucosa is also deep some of the signs of
with no ulcerations red in color Kawasaki Disease
Tongue is red and has
strawberry-like texture Source: Textbook of
No ulcerations in oral Pediatric Infectious
mucosa Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
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Areola is round or oval Areola is small and brown Normal
and color is light pink to in color
dark brown
Nipples are round, and Nipples are round and Normal
equal in size almost in size
Finger and Inspection Vascular and pinkish in Fingers and toes are Changes in
Toe Nails and color desquamated, extremities such as
Palpation edematous, and reddish edema, desquamation,
in color and redness are signs
of Kawasaki Disease
Smooth texture Smooth texture Normal
Intact epidermis Intact epidermis Normal
Capillary refill in 3-5 Capillary refill of 3 seconds Normal
seconds
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Abdomen Inspection, Unblemished skin, Presence of Presence of
Auscultation, uniform in color erythematous and polymorphous
Palpation polymorphous rashes on exanthema or rashes
the trunk is one sign of
Kawasaki Disease
no evidence of liver no evidence of liver Normal
enlargement enlargement
Audible bowel sounds Audible bowel sounds at Normal
12 per minute; abdomen
produces a growling sound Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
16
Muscles Inspection, Equal size on both sides Symmetrical in size on Normal
Palpation of the body; no both sides of the body
contractures
Good muscle tone, firm Good muscle tone with no Normal
with smooth coordinated signs of uncoordinated
movements motor movement
Source of Normal Figures: Fundamentals of Nursing: Concepts, Process, and Practice Seventh Edition by Kozier, Barbara and
Erb, Glenora
Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family Fifth Edition by
Pillitteri, Adele
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ANATOMY
I. Heart
The heart functions as the primary organ for blood circulation in the
human body. It is responsible for delivering un-oxygenated blood from the
venous system to the lungs and oxygenated blood from the lungs to the arterial
circulation. Additionally, the heart propels blood throughout the systemic
(arterial) circulation to bring nutrients, vital enzymes, hormones, and drugs to the
tissues and organs of the body. The image of the heart, its parts and functions,
are illustrated in Figure 1 and Table 1 respectively.
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TABLE 1: THE PARTS OF THE HEART AND CORRESPONDING FUNCTION
STRUCTURAL PARTS FUNCTION
Superior Vena Cava (SVC) One of the two main veins that drains un-
oxygenated blood to the right atrium
Blood from the head and upper body
drain into the SVC
Inferior Vena Cava (IVC) The second main vein that drains un-
oxygenated blood to the right atrium
Blood from the legs and lower torso drain
into the IVC
Aorta The largest single blood vessel in the
body
Passageway for oxygen-rich blood from
the left ventricle into the systemic
circulation
Pulmonary Artery The only artery in the body that carries
deoxygenated blood
Passageway of deoxygenated blood from
the right ventricle to the lungs
Pulmonary Vein The only vein in the body that carries
oxygenated blood
Carries oxygenated blood from the lungs
to the left atrium
Right Atrium A chamber of the heart that receives
deoxygenated blood from the SVC and
IVC
Pumps blood into the right ventricle via
the tricuspid valve
Right Ventricle Receives deoxygenated blood from the
right atrium via the tricuspid valve
The tricuspid valve closes after the right
ventricle fills up with blood and the
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pulmonary valve opens to allow
deoxygenated blood to flow into the
pulmonary artery
Left Atrium Receives oxygenated blood from the
pulmonary vein
Blood from this chamber empties into the
left ventricle via the mitral valve
Left Ventricle Arguably the largest chamber of the
heart, receives oxygenated blood from
the left atrium via the mitral valve
The mitral valve is open as the left
ventricle fills up with blood from the left
atrium and it closes once the left ventricle
is filled. The aortic valve opens as the
left ventricle contracts, sending
oxygenated blood into the aorta and into
the systemic circulation
Atrioventricular Valves The tricuspid and mitral valves ensure
one-way blood flow within the chambers
of the heart
The tricuspid valve is the gateway
between the right atrium and the right
ventricle
The mitral valve is the gateway between
the left atrium and the left ventricle
Semilunar Valves The pulmonary and aortic valves ensure
one-way blood flow into the pulmonary
artery and aorta respectively
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II. Coronary Arteries
The coronary arteries constitute the coronary circulation that supplies
oxygenated blood to the heart itself. These arteries receive their blood supply
from openings in the aorta called the coronary ostia.
A major complication of Kawasaki Disease is the development of coronary
aneurysms and coronary thrombosis, thus making the discussion of the coronary
arteries relevant. Ruptured coronary aneurysms lead to massive bleeding and
ischemia, eventually resulting to myocardial infarction.
The main branches of the coronary arteries and the areas of the heart
they supply are detailed below (Figure 2 and Table 2).
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Table 2: The Branches of the Coronary Arteries
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III. Vascular System
The vascular system is made up of the arteries and veins of the body.
Arteries branch into smaller arterioles, which branch further into capillaries.
Capillaries serve as the site where nutrient exchange between the blood and
tissues occur. Blood from the capillaries then enter venules that eventually join
together to form larger veins. The arteries serve as the channels for oxygenated
blood (systemic circulation) and the veins serve as the channels for
deoxygenated blood.
As a systemic vasculitic disease, Kawasaki Disease causes inflammation
of the blood vessels resulting to edema, increased permeability of the vessels,
and coronary aneurysms (weakening of the blood vessel walls). Figure 3 and
Table 3 briefly discuss the structure and functions of the vascular components.
23
Table 3: Comparison of Arteries and Veins
ARTERIES PARTS VEINS
Thinner than the tunica Tunica Adventitia (outer Thickest layer
media layer)
Thicker than the tunica Tunica Media (middle Thinner in veins
adventitia allowing layer)
vasoconstriction and
vasodilation
Same Tunica Intima (inner layer) Same
Narrower Lumen Wider to accommodate
valves
Absent Presence of Valves Present; to ensure the one-
way flow of blood back to
the heart
Fastest in arteries and gets Blood Flow Slow in the venules, but
slower when entering the increases speed as it
arterioles and capillaries passes through the veins
(valve-related)
Aorta (largest), pulmonary Major Blood Vessels Superior and inferior vena
artery, carotid arteries, cavae, jugular veins,
subclavian artery, subclavian veins, hepatic,
brachiocephalic, abdominal iliac, femoral, hepatic portal
aorta, common iliac, brachial
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Figure 4: Arteries of the Body
The lymph nodes are some of the major structures of the lymphatic
system, which works closely with the circulatory system to bring interstitial fluid
back into the blood circulation. Functionally, however, lymph nodes are part of
the hematologic and immune systems because large numbers of lymphocytes,
monocytes, and macrophages reside in these nodes. These cells are mobilized
and join the circulating blood during infection or inflammation.
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PATHOPHYSIOLOGY
Diagnosis of Kawasaki Complications if untreated
Signs and symptoms in Disease based on without IVIG 10 days after onset
patient diagnostic criteria of of fever
disease;
Age is the only probable
predisposing factor in
patient
Diagnostic indicators
Sources:
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Discussion:
The etiology of Kawasaki Disease is still unknown. Studies have failed to identify
a pathologic agent that causes the disease. Most clinicians believe the disease has an
infectious nature due to the presence of seasonal outbreaks in Japan. The only non-
modifiable risk factors with considerable theoretical basis are age and race. Most cases
involve children below 10 years of age and Japanese children appear to be at a higher
risk of acquiring the disease. However, the incidence of KD in Asians and other Pacific
Islanders is higher compared to Westerners of Caucasian or African descent.
The patient manifested 5 out of the 6 signs in the criteria for diagnosing
Kawasaki Disease. The patient had remittent fever for 6 days, had rashes that started
in the arms and spread to the trunk, oral cavity changes manifested by cracked lips,
strawberry tongue, and reddened oral mucosa, bilateral conjunctivitis, and a palpable
lymph node on the lefts side of the neck. These clinical manifestations were supported
by the hematological test and vital signs of the patient: a temperature of 39.5°C,
elevated platelet (thrombocytosis) and ESR (inflammatory response) levels, and a “left
shift” (increased production of mature leukocytes) in the patient’s WBC differential
results. The hematological results further provide evidence of the multi-system
affectations of the disease indicating signs of inflammation (vasculitis in KD), formation
of blood clots, and abnormal increase in WBCs (manifested in lymphadenopathy.
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DIAGNOSTIC EXAMINATIONS
Hematology Section - PCMC
Differential Count
30
PARAMETERS RESULTS NORMAL FINDINGS ANALYSIS
VALUES
Hematology
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Date of Release: January 25, 2010
Differential Count
32
range
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DRUG STUDY
Drug Name: 2.5g/50ml 10 vials: Improves immunity Kawasaki Patients with Tenderness, - Do not administer to
by binding to and Syndrome anaphylactic reaction to muscle stiffness at patients with history of
IMMUNOGLOB- Test Dose I: neutralizing IGIV injection site, allergy to gammaglobulin
ULIN IV 0.01x11.5kgx60 Prophylaxis after
pathogens, thereby nausea, vomiting,
= 7cc for 30mins exposure to - Instruct patient to report
Drug Class: increasing chills, fever,
antibodies against Hepatitis A headache. symptoms occurring
Test Dose II:
Passive immune- 0.02x11.5kgx60 bacterial, viral, during or after therapy.
globulin B-cell chronic
=14cc parasitic, and
lymphocytic - Use with caution in
mycoplasmic
Test Dose III: leukemia pregnant women-
antigens. Acts
0.03x11.5kgx60 Pregnancy C; safety not
through Pediatric HIV
=21cc established
antimicrobial and infection
Test Dose IV: antitoxin - Have epinephrine 1:1000
0.04x11.5kgx60 neutralization. immediately available at
=28cc time of injection in case of
anaphylactic reaction
Translate
remaining 390cc to
- Do not mix immune
24cc/hr for 16hrs
globulin with any other
medications
- Monitor patient’s VS
continuously
Drug Name: 300mg/tab; 1 tab It acts in the Mild to moderate Allergy to NSAID or Acute aspirin - Give drug with food or
q6 PO thermoregulatory pain salicylates toxicity: tachypnea, after meals if GI upset
ASPIRIN center of the hemorrhage, occurs.
hypothalamus to Fever Hemophilia; excitement,
Classification:
block effects of hemorrhagic states; confusion - Use the drug only as
Antipyretic, Inflammatory impaired renal function; suggested; avoid
pyrogen
analgesic, NSAID conditions- chickenpox; pregnancy GI: nausea, overdose.
Also has anti- rheumatic fever, dyspepsia,
inflammatory, anti- rheumatoid heartburn,
platelet, and arthritis, epigastric
analgesic osteoarthritis discomfort,
properties anorexia
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NURSING CARE PLAN
The following nursing problems were based on the data gathered for this study:
I. Actual Nursing Problems
1. Elevated body temperature related to systemic inflammation of blood
vessels secondary to present disease
2. Impaired skin integrity related to accumulation of fluid in the interstitial
spaces of hands and feet secondary to present disease
3. Impaired oral mucous membrane related to inflammation of oral mucosa
secondary to present disease
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ACTUAL NURSING PROBLEMS
1. Elevated body temperature related to systemic inflammation of blood vessels secondary to present disease
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Elevated body Present Short-term: Independent: After 2 hours of
NONE temperature disease nursing
related to After 2 hours Check Assessment intervention, the
Objective: systemic of nursing temperature and of all vital patient’s body
Temp – 38.4°C; inflammation Systemic intervention, other vital signs signs is temperature
of blood inflammation the patient’s prior to integral to was lowered to
Warm to touch; vessels of blood temperature interventions; planning and 37.8°C; to
secondary to vessels will normalize intervention; continue
Irritable and present at 37.5°C. interventions
restless; disease Administer tepid TSB is an until body
Release of sponge bath to independent temperature
Uncontrolled pyrogens lower nursing normalizes
crying temperature; function that
lowers core
temperature;
Elevated body
temperature Provide a change Increasing
of clothes and patient
sheets to promote comfort can
increased ease irritability
comfort; and
restlessness
associated
with fever;
Dependent:
Administer aspirin Aspirin serves
as ordered; as an
antipyretic,
anti-
inflammatory
and anti-
platelet drug
in Kawasaki
Disease
Check the flow Proper
rate of IVIG and regulation of
watch out for IVIG infusion
signs of adverse is important to
effects prevent side
effects
2. Impaired skin integrity related to accumulation of fluid in the interstitial spaces of hands and feet secondary to
present disease
38
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired skin Present Short-term: Independent: After 6 hours of
NONE integrity disease After 6 hours nursing
related to of nursing Assess the hands Assessment intervention,
Objective: accumulation intervention, and feet for extent of sites of skin integrity
of fluids in Systemic skin integrity of dryness and edema will improved with
+ 1 edema of interstitial inflammation improved as edema; dictate controlled
hands and feet; spaces of of blood evidenced by provision dryness of the
hands and vessels controlled interventions; skin ; skin is
Skin appears dry feet dryness of the more moist on
and shiny; secondary to skin Assess mobility of Mobility is a sites of edema
present Increase in fingers, toes, sign of
With erythema of disease histamine Long-term: hands, feet, sufficient
hands and feet; release wrists, and blood flow to
After 3 to 4 ankles; sites;
desquamation of days of
fingers and toes Greater nursing Apply RICE R- rest;
permeability intervention, technique in I – ice to
of blood skin integrity management of decrease
vessels problems edema; inflammation;
related to C–
edema will compression
Vascular fluid resolve as to promote
moving to evidenced by venous return
interstitial edema score and lymphatic
spaces of of 0 from +1 drainage of
hands and fluid;
feet E – elevate
above the
heart for
venous return;
3. Impaired oral mucous membrane related to inflamed oral mucosa secondary to present disease
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired oral Present Short-term: Independent: After 3 hours of
40
NONE mucous disease nursing
membrane After 3 hours Assess the extent, Assessment interventions,
Objective: related to of nursing characteristic, and of the fissures fissured and
inflamed oral Inflamed oral intervention, severity of the and cracks on cracked lips
With fissured, mucosa mucosa fissures and fissures and the lips will were managed
cracked lips; secondary to cracks in the cracks on the lips; affect as evidenced by
present lips will be interventions controlled
With disease Poor blood controlled and to be given; dryness of the
erythematous perfusion to lessened lips
lips; oral mucous Assess if there is Fissured and
membrane Long-term: difficulty in cracked lips
red and inflamed swallowing or can cause
oral mucosa; After 3 to 4 alterations in difficulty in
Impaired oral days of feeding; feeding,
Strawberry-like mucous nursing especially in
tongue with membrane intervention, infants;
papules; (evidenced by fissures and
cracked lips) cracks will Provide oral Moistening
Irritable when resolve as rinses using tap dried mucosa
being given evidenced by water or saline will prevent
feedings moist lips with drops to moisten worsening of
the absence mucosa; cracks and
of cracks and prevent new
fissures ones from
developing
Independent:
Promote a Proper
balanced diet with nutrition will
low sodium ensure growth
content; and
development;
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DISCHARGE PLANNING
Medication
IVIG: educate parents regarding side effects of drug such as chills, fever,
and headache
Advise parents to report any changes in the patient related to drugs being
taken
Exercise
Advise parents of adequate rest and sleep for up to 2 to 3 days after discharge to
promote recovery
Advise parents to gradually increase activities; start with light activities until
tolerated before engaging in more strenuous activities
Encourage parents to have patient engage in normal activities of daily living such
as self-feeding, dressing, and walking
Constantly monitor activity and exercise pattern to detect any abnormalities such
as cardiac affectations/sequelae of Kawasaki Disease
Treatment
Health Teachings
47
Encourage parents to promote a safe, comfortable, and clean environment
conducive to recovery of patient
Provide nutritional teaching to parents to foster improved nutritional and fluid
intake as well as promote balanced diet
During recovery, patient should not be brought to crowded places to prevent
community-acquired infections
Advise mother to complete all immunizations and booster shots for patient once
cleared by physician
Out Patient
Remind the family on their follow up check up with their physician
Encourage to take routine cardiac diagnostic examinations (i.e. MRI, CTscans of
the heart, and 2D echocardiography) to determine presence of cardiac
affectations/complications of disease
Diet
Encourage to have the three basic food groups in the diet while controlling salt
intake
Encourage to increase fluid intake
Encourage to prepare foods that are rich in vitamins and minerals to improve
immune system
Continue milk feeding and solid food combination and introduce new viands to
improve appetite and expand food variety
Spiritual
Guided by the family, help the patient to establish deep personal relationship with
God in everyday of her waking moment
With guidance from parents and family, help the patient find happiness in her
present situation
Aid patient in holistic development of self to promote overall wellness
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REFERENCES
Books
Internet
Gordon, John B. et al. When Children with Kawasaki Disease Grow Up: Myocardial and
Vascular Complications in Adulthood., Journal of the American College of
Cardiology as seen on http://www.medscape.com/viewarticle/712188
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