Leptospirosis Case
Leptospirosis Case
CASE STUDY IN
LEPTOSPIROSIS
SUBMITTED BY:
Ciryl P. Amoto
BSN LEVEL IV
SUBMITTED TO:
Ariel Ortuoste, RN, MAN
Clinical Instructor
ICU Rotation
CONTENTS
I. INTRODUCTION
II. PATIENT PROFILE
III. PATIENT HISTORY
IV. GORDON’S LEVEL OF HEALTH FUCTIONING
V. ANATOMY AND PHYSIOLOGY
VI. RELATED LITERATURE
VII. PATHOPHYSIOLOGY
VIII. LABORATORY RESULTS
IX. COURSE IN THE WARD
X. NCP
XI. DRUG STUDY
I. INTRODUCTION
Leptospirosis is a relatively rare bacterial infection that affects people and animals. It can pass
from animals to humans when an unhealed break in the skin comes in contact with water or
Several species of the Leptospira genus of bacteria cause leptospirosis. It can progress to
conditions such as Weil’s disease or meningitis, which can be fatal.
The condition does not usually pass from one person to another.
The bacteria can enter the body through open wounds, the eyes, or mucous membranes.
Animals that transmit the infection to humans include rats, skunks, opossums, foxes, and
raccoons.
Leptospirosis is more common in tropical areas, where the World Health Organization
(WHO) estimate that it affects 10 or more people in every 100,000 each year.
In temperate climates, it probably affects between 0.1 and 1 per 100,000 people. In an
epidemic, it can affect 100 or more in every 100,000 people.
Ward: ICU
Date of Admission: February 21,2020 7:40am
Patient’s Name: G. S. G.
Address: N/A
Age: 31 years old
Gender: Male
Birthdate: September 2, 1989
Educational Status: N/A
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Married
Occupation: Stockmen
Health Care Financing:
Informant: Mother
Reliability: Chart
Admission Data:
1. Chief Complaint: Fever
2. Initial Diagnosis: Leptospirosis
3. Final Diagnosis: Leptospirosis
4. Attending Physician: Lou Jorel P. Tia M.D
III. PATIENT HISTORY
CHIEF COMPLAINT
PAST MEDICAL HISTORY
-N/A
FAMILY HISTORY with GENOGRAM
Patient continues
Elimination Urine is green and Urine is yellow and
elimination via
Pattern poops everyday reddish, stool is soft
catheter
Causative Agent:
Contact with soil, water or plants
that have been contaminated by
animal urine.
LEPTOSPIROSIS
VIII. LABORATORY RESULTS
HEMATOLOGY
Differential
Count
Neutrophil 0.84 0.36-0.66
Lymphocytes 0.12 0.22-0.40
Monocyte 0.04 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.62 0.36-0.66
Lymphocytes 0.38 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.75 0.36-0.66
Lymphocytes 0.21 0.22-0.40
Monocyte 0.04 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.84 0.36-0.66
Lymphocytes 0.14 0.22-0.40
Monocyte 0.02 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.85 0.36-0.66
Lymphocytes 0.15 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.89 0.36-0.66
Lymphocytes 0.11 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.93 0.36-0.66
Lymphocytes 0.07 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.87 0.36-0.66
Lymphocytes 0.13 0.22-0.40
Monocyte 0.02 0.04-0.08
Eosinophil 0.06 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY
Differential
Count
Neutrophil 0.85 0.36-0.66
Lymphocytes 0.15 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
CLINICAL CHEMISTRY
Test Result
Test Result
Chemical Examination
Protein +1
Sugar Negative
Specific Gravity 1.030
pH 5.0
IX. COURSE IN THE WARD
OBJECTIVE:
Vital signs taken:
BP: 130/90 COLLABORATIVE:
PR: 70
RR: 20
T: 36 C
O2: 97%
Brand Name:
B.
Available Therapeutic:
Dosage:
Route:
Frequency:
C. Pregnancy
Pharmacokinet Category:
ics:
Onset:
Peak:
Duration:
Half Life:
REFERENCES:
https://www.ahajournals.org/doi/10.1161/STROKEAHA.114.006320
https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-
causes/syc-20350113
https://www.healthline.com/health/cerebrovascular-accident#diagnosis
https://www.slideshare.net/ReihchelleBayad/gordons-
11functionalhealthpatterns
https://www.scribd.com/doc/36707103/Anatomy-and-Physiology-CVA