Grand Case Press

8/3/2019 Grand Case Press

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Introduction

Leptospirosis (also known as Weil's disease, Weil's syndrome, canicola fever, canefield fever, nanukayamifever, 7-day fever, Rat Catcher's Yellows, Fort Bragg fever, and Pretibial fever) is a disease known to cause heating upand causing redness of the hands. It is caused by infection with bacteria of the genus Leptospira , and affects humans aswell as other mammals, birds, amphibians, and reptiles.

The disease was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice and nephritis". Leptospira was first observed in 1907 from a post mortem renal tissue slice. In 1908,Inada and Ito first identified it as the causative organism and in 1916 noted its presence in rats.

Though recognised among the world's most common diseases transmitted to people from animals, leptospirosis isnonetheless a relatively rare bacterial infection in humans. The infection is commonly transmitted to humans by allowingwater that has been contaminated by animal urine to come in contact with unhealed breaks in the skin, the eyes, or withthe mucous membranes. Outside of tropical areas, leptospirosis cases have a relatively distinct seasonality with most of them occurring AugustSeptember/FebruaryMarch.

Leptospirosis is caused by a spirochaete bacterium called Leptospira spp. There are at least five serovars of importancein the United States and Canada, all of which cause disease in dogs (Icterohaemorrhagiae, Canicola, Pomona,Grippotyphosa, and Bratislava).

There are other (less common) infectious strains. Genetically different leptospira organisms may be identical serologicallyand vice versa. Hence, an argument exists on the basis of strain identification. The traditional serologic system isseemingly more useful from a diagnostic and epidemiologic standpoint at the moment (which may change with further development and spread of technologies like polymerase chain reaction (PCR)).

Leptospirosis is transmitted by the urine of an infected animal and is contagious as long as it is still moist. Although rats,mice and moles are important primary hosts, a wide range of other mammals including dogs, deer, rabbits, hedgehogs,


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cows, sheep, raccoons, possums, skunks, and certain marine mammals are able to carry and transmit the disease as

secondary hosts. Dogs may lick the urine of an infected animal off the grass or soil, or drink from an infected puddle.There have been reports of "house dogs" contracting leptospirosis apparently from licking the urine of infected mice thatentered the house. The type of habitats most likely to carry infective bacteria are muddy riverbanks, ditches, gullies, andmuddy livestock rearing areas where there is regular passage of either wild or farm mammals. There is a direct correlationbetween the amount of rainfall and the incidence of leptospirosis, making it seasonal in temperate climates and year-round in tropical climates.

Leptospirosis is also transmitted by the semen of infected animals. Slaughterhouse workers may contract the diseasethrough contact with infected blood or body fluids.

Humans become infected through contact with water, food, or soil containing urine from these infected animals. This mayhappen by swallowing contaminated food or water, or through skin contact. The disease is not known to be spread fromperson to person and cases of bacterial dissemination in convalescence are extremely rare in humans. Leptospirosis iscommon among water-sport enthusiasts in specific areas as prolonged immersion in water is known to promote the entryof the bacteria. Surfers and whitewater paddlers are at especially high risk in areas that have been shown to contain thebacteria, and can contract the disease by swallowing contaminated water, splashing contaminated water into their eyes or nose, or exposing open wounds to infected water. Occupations at risk include veterinarians, slaughterhouse workers,farmers, sewer workers, and people working on derelict buildings. Rowers are also sometimes known to contract thedisease.


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Ge n e ral Obj e ctiv es:

This case analysis was designed to develop a holistic and patient centered nursing care and responsibilities. This is tobroaden the knowledge of the analyst as well as the student with regards to Lep to sp iro s is, this is also designed toenhance skills and attitudes in the application of nursing process and management of the disease.

S pe cific Obj e ctiv es:

To identify the factors (predisposing, precipitating or etiologic agent if any) that causes the disease.

-To identify the sign and symptoms manifested by the patient with Leptospirosis and perform further assessment to beable to recognize appropriate nursing intervention to be rendered.

-Discuss the anatomy and physiology and how it is being altered the disease process. -To have the pathophysiology and

to trace the occurrence of Leptospirosis.

-To utilize properly the nursing process (assessment, diagnosis, planning, intervention, evaluation) as the framework for the care of the patient.


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-To select appropriate nursing diagnosis for the patient with Leptospirosis based on assessment findings.

-To learn various medications, it's condition, adverse effects & accompanying nursing responsibilities.

-To put into action what we have learned in the school (such as nursing process) and apply our knowledge in providingquality and individualized nursing care.

-To enhance group's attitude, like discipline, cooperation, leadership abilities and teamwork in making and forming thiscase analysis.

-To involve the patient's family in the implementation of nursing management throughout hospital experienced.

NUR SIN G HISTO RY

A. Biogra ph ical Data

Patient Name: Patient X

Address: XXXXXXXXX

Date of Birth: 6-22-93

Birth Place: Quezon City


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Occupation: Student

Source of health Assistance: nearest health center on Las Pinas CitySource of Referral: Las Pinas healh center

Emergency Contact Person and Number: RVB / 0999-xxx-xx-xx

B. R e a s on for seek ing H e alt h Car e

CC: vomiting and body weakness.

Objective Data:

yellowish skin color

Subjective Data:

(+) dizziness felt

C. Hi s tory of Pr ese nt Illn ess

1 Week Prior to Admission:

The patient is suffering from severe vomiting, abdominal pain and dizziness. His mother brought him to Las PinasGen. Hosp, and the physician noted that he has Dyspepsia and Electrolyte Imbalance. His Doctor suggested him to havea laboratory test such as CBC, UA, PC, ECG and Chest x-ray.

10 Hours Prior to admission:


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He still felt the following Condition (said above), After the lab results were revealed, Doctor noted the principaldiagnosis as acute renal failure resolving t/c Leptospirosis.

Pa s t Me dical Hi s tory

This was his first hospitalization.

D. Pa s t H e alt h His tory

Medical History: Cough and Cold, Fever, Chicken pox and Measles during childhood.

Surgical History: He never undergone operation..

Medications: Paracetamol, Neozep, Anti-histamine

Allergies: No known allergies on food and medications

Injuries and accidents: None

Childhood Illness immunization: Complete childhood immunization in School and Health Centers.

E. Family H e alt h His tory

Patient Age: 18 years old

AGE HEALTH STATUS

Siblings: Has 4. 34y/o eldest no pertinent data

Patients mother: 54y/o no pertinent data


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Patients father Deceased History of hypertension.

F. Social Hi s tory

a. Alcohol use: The patient said that she never drink alcohol.

b. Drug use: The patient said she never used any prohibited drugs

c. Tobacco use: No history of smoking as stated by the patient

d. Sexual practice: Not Active

e. Travel history: From Quezon City, they move their house at Las Pinas City

f. Home environment: The patient said their house is quiet spacious and conducive for healthy living.

g. Hobbies and Leisure act: The patient is the youngest in the family. He said hispast time activities are playing computer and using cell phone.

h. Education: He is currently a college student.

i. Economic status: Their familys main source of income is from his eldest brothers job as well as his motherssideline job.

j. Religion: Roman Catholic

k. Ethnic background: Rules and policies of their religion are slightly followed by the Family. Examples is going tochurch once a week.

ftVital Signs ( upon admission)


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BP: 130/100 mmHg

Pulse rate: 96bpmRR: 59 cpm

Temp: 37 C

*Pertinent P.E done

GORDONS FUNCTIONAL HEALTH PATTERN

COMPONENTS BEFOREHOSPITALIZATION

DURINGHOSPITALIZATION

ANALYSIS

1. Health perception/management

Whenever the pt gets sick,he immediately seeksmedical attention to thenearest health center.

The pt realized theimportance of regular check-ups. He still believes thatimmunity is the mostimportant aspect in attainingmaximum health

Pts health awareness ishigh; she accepts theresponsibilities & doespreventive measurements todecrease the possibleoutcome of a disease or health deterrent.

2. Nutritional/ metabolic The pt said, he is not choosy

in the food, but he didnt likeeating junk foods.

The pt is in NPO. Because he w ill be

undergone on an ultrasound.3. Elimination The pt voids/ bowel

movement3x a dayThe pt doesnt eliminate hisbowel movement &no urineoutput.

Because he is in NPO, thatswhy he often have anyoutput.

4. Activity/ Exercise The pts hobbies are playingcomputer and using cellphone.

The pt cannot do hishobbies because of bodyweakness.

The pt needs a CBR toreturn back his bodystrength.


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5. Sleep/ Rest The pt used to sleep at 1ambecause of playing

computer.

The pt always felt sleepybecause hes bored and has

no choice but to sleep.

Adequate sleep will help himto pay for the times that he

is sleeping late at nightbefore he was hospitalized.6. Cognitive/ perceptual The pt is alert, active and

can response immediately.The pt can still answer to thequestions asked to him.

Nothing has change to ptsperception.

7. Self-perception/ self-concept

The pt is in good conditionand in good condition. Ahappy-go-lucky person.

The pt is quite depressedbecause he doesnt feelgood about his self.

When illness started, the ptdoesnt feel good anymoreabout his self, but he doesntlose hope, he believes thathe will recover on his illness.

8. Role/ relationship The pt is the youngestamong his 4 siblings.

The pt is taken care of by hismother & sister.

Since he is the youngest, allof the attention was givenunto him.

9. Sexuality/reproductive

Pt doesnt used any familyplanning.

He doesnt think aboutsexuality/reproductive. Buthe stated that he wascircumcised at the age of 12y/o.

The pts reproductive systemis normal.

10. Coping/ StressTolerance

If he has a problem, hechoose to live alone.

He let his family resolvedtheir problem.

Even the pt is happy-gog-lucky, deep inside he pity hisfamily because of theproblem they are

experiencing.11. Values/ Beliefs The pt is a roman catholicbut doesnt want to go tochurch except for midnightmass during Christmas.

The pt said that she will goto church after she getsdischarge from the hospitalas a thanks giving

The pt realized that God isstill the center of all theexistance on earth.


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EE YYEE SS

BBuu llbb aa r r CC oo nn j juu nn cc ttiivvaa

IInn ss pp ee cc ttiioo nn TTr r aa nn ss pp aa r r ee nn tt,,

cc aa pp iillllaa r r iiee ss ss oo mmee ttiimmee ss ee vviidd ee nn tt,, ss ccllee r r aa aa pp pp ee aa r r ss wwhh iittee ((ddaa r r kkee r r oo r r yyee lllloo wwiiss hh aa nndd ss mmaa llll bb r r oo wwnn mmaa ccuu llee ss iinn dd aa r r kk--ss kkiinn nnee dd cclliiee nn ttss )) SS hh iinn yy,, ss mmoo oo tthh ,, pp iinn kk oo r r r r ee dd ..

TTr r aa nn ss pp aa r r ee nn tt,,

cc aa pp iillllaa r r iiee ss aa r r ee ee vviidd ee nn tt,, ss ccllee r r aa iiss yyee lllloo ww..

TThh ee pp aa ttiiee nn tt hh aa ss

aa bb nn oo r r mmaa ll cc oo nn j juu nn cc ttiivvaa ..

NNoo ttee f f oo r r j jaa uu nn ddiicc ee

ss cc llee r r aa ((lliivvee r r ddiiss ee aa ss ee ));; ee xxcc ee ss ss iivvee llyy pp aa llee ss cc llee r r aa ;; llee ss iioo nn ss oo r r nn oo dd uullee ss ((bb aa cc ttee r r iiaa ll aa gg ee nn ttss ))

PP aa llpp ee bbr r aa ll cc oo nn j juu nn cc ttiivvaa ((lliinniinngg tthh ee ee yyee lliidd ss ))

PP aa llpp aa ttiioonn ,, iinn ss pp ee ccttiioo nn

NNoo ee dd ee mmaa oo r r ttee nn dd ee r r nnee ss ss oo vvee r r llaa cc r r iimmaa ll ggllaa nndd

TThh ee cc oo nn j juu nn cc ttiivvaa iiss dd r r yy,, ss mmoo oo tthh aa nn dd yyee lllloo ww..

TThh ee pp aa ttiiee nn tt hh aa ss aa bb nn oo r r mmaa ll aa nn dd pp oo oo r r cc oo nn j juu nn cc ttiivvaa ..

EE xxttr r ee mmee llyy pp aa llee :: pp oo ss ss iibbllee aa nn ee mmiiaa ;; ee xxttr r ee mmee llyy r r ee dd ;; iinn f f llaa mm mmaa ttiioo nn ;; nn oo dd uullee ss oor r oo tthh ee r r llee ss iioo nn ss aa r r ee nn oo tt nn oo r r mmaa ll..

SS kkiinn CC oolloo r r IInn ss pp ee cc ttiioo nn SS kkiinn uu nniif f oor r mm cc oo lloo r r ((ss aa mmee aa ss ss kkiinn oo f f aa bb dd oo mmee nn oo r r bb aa cc kk)) ss kkiinn ss mmoo oo tthh aa nn dd iinn ttaa cctt

SS kkiinn uu nniif f oor r mm cc oo lloo r r ((ss aa mmee aa ss ss kkiinn oo f f aa bb dd oo mmee nn oo r r bb aa cc kk)) ss kkiinn ddr r yy aa nn dd

yyee lllloo wwiiss hh

A Abb nn oo r r mmaa ll ss kkiinn cc oo lloo r r oo f f cc hhee ss tt

GG ee nn ee r r aa lliizz ee dd dd iiss cc oolloor r aa ttiioo nn


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Urinalysis

Examination Normal Values Findings Analysis

MACROSCOPIC EXAM

MMOO UUTTHH LLiipp ss ss yymm mmee ttr r yy oo f f cc oo nn ttoo uu r r ,, cc oo lloor r aa nn dd ttee xxttuu r r ee

IInn ss pp ee cc ttiioo nn UUnn iif f oor r mm pp iinn kk cc oo lloo r r ss oo f f tt,, mmoo iiss tt,, ss mmoo oo tthh ttee xxttuu r r ee ,, ss yymm mm ee ttr r yy oo f f cc oo nn ttoo uu r r ,, aa bbllee ttoo ppuu r r ss ee lliipp ss ..

PP aa llee iinn cc oolloo r r ,, ss oo f f tt,, mmoo iiss tt,, ss mmoo oo tthh ttee xxttuu r r ee ss yymm mm ee ttr r yy oo f f cc oo nn ttoo uu r r ,, iiss aa bbllee ttoo pp uu r r ss ee lliipp ss ..

TThh ee pp aa ttee nn ttss ttoo nn gg uu ee iiss nnoo r r mmaa ll wwiitthh nn oo llee ss iioo nn ss ..

DDee vviiaa ttee dd f f r r oo mm cc ee nn ttee r r ((hh yypp oo gglloo ss ss aa ll oo r r 11 22tthh cc r r aa nniiaa ll nn ee r r vvee ));; ss mmoo oo tthh r r ee dd ttoonn gg uu ee ((VViitt.. BB11 22 oo r r BB33 dd ee f f iicc iiee nn cc yy));; dd r r yy f f uur r r r yy ttoo nn gg uu ee ((f f lluuiidd dd ee f f iicc iitt));; wwhh iittee cc oo aa ttiinn gg ((oo r r aa ll yyee aa ss tt iinn f f ee cc ttiioo nn))

IInn nn ee r r lliipp ss aa nn dd bb uu cc cc aa ll mmuu ccoo ss aa

IInn ss pp ee cc ttiioo nn aa nn dd pp aa llppaa ttiioo nn

UUnn iif f oor r mm pp iinn kk cc oo lloo r r ,, mmoo iiss tt ss mmoo oo tthh ,, ss oo f f tt,, gg lliiss ttee nniinn gg aa nn dd ee llaa ss ttiicc ttee xxttuu r r ee ..

SS lliigg hh ttllyy pp aa llee iinn cc oo lloo r r ,, mmoo iiss tt,, ss mmoo oo tthh ,, gg lliiss ttee nniinn gg aa nn dd ee llaa ss ttiicc ..

PP aa llee ss // ppaa lllloo r r mmaa yy iinn dd iicc aa ttee bb lloo oo dd cc iir r cc uullaa ttiioo nn pp r r oo bbllee mm ((aa nn ee mmiiaa )) oo nn pp aa ttiiee nn tt..

PP aa lllloo r r ,, llee uu kkoo ppllaa kkiiaa ,, r r ee dd ,, bbllee ee dd iinn gg ,, ee xxcc ee ss ss dd r r yynn ee ss ss ,, mmuu cc oo ss aa ll cc yyss ttss ,, uu llccee r r aa ttiioonn ss ,, nn oo dd uullee ss ..


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HEMATOLOGY

Examination Normal Values Findings Analysis

Complete Blood Count

Hemoglobin 12- 18 g/L 8.9 White blood cells constitutethe

Hematocrit 0.37- 0.47 0.27 bodys primary defensesystem

White Blood Cells 4- 11x 10/ L 4-2 against foreign organisms,tissue

RBC Count 4-2 6.0 3.23 and other substances. Aninc.

Neutrophil 55- 70 96 WBC count is termed asleukocy-


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Lymphocytes 0.20- 0.05 3 tosis. A total WBC countindicate

Monocyte 0.02- 0.05 1 the degree of response toa path

Ologic process.Acute leukocys-Tosis is initially accompanied by Changes in WBC count population , followed bychanges within The individual WBCs

Medical Management

Oxygen

The patient was ordered to have 3 to 4 liters per minute of oxygen. Because he has having tachypnea

Blood transfusion

From the previous lab result which is his hematology his Hgb,Hct and RBC are decreased.

Ranitidine

The patient is taking this medicine because hes having heart burn,acid indigestion and sour stomach


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MMEE DDIICC A ATTIIOO NN IINNDDIICC A ATTIIOO NN CC LL A ASS SS IIFF IICC A ATTIIOO NN CC OO NNTTRR A AIINNDDIICC A ATTIIOO NN A ANNDD A ADDVVEE RR SS EE EE FF FF EE CC TT

NNUURR SS IINNGG RR EE SS PP OO NNSS IIBBIILLIITTYY

GG EE NNEE RR IICC

NN A AMMEE ::RR aa nn iittiiddiinn ee

BBRR A ANNDD NN A AMMEE :: ZZaa nn ttaa cc

TTr r ee aa ttmmee nn tt aa nn dd pp r r ee vvee nn ttiioo nn oo f f hh ee aa r r ttbb uu r r nn ,, aa cciidd iinn ddiiggee ss ttiioo nn ,, aa nn dd ss oo uur r ss ttoo mmaa cc hh ..

T T hh ee r r aa p p ee uu t t i i c c :: A Ann ttii--uullccee r r aa ggee nn ttssP P hh aa r r mm aa c c oo l l oo g g i i c c :: HHiiss ttaa mmiinn ee HH22 aa nn ttaa gg oo nniiss ttss

CC NNSS ::

CC oo nn f f uu ss iioo nn ,, ddiizz zziinn ee ss ss ,, dd r r oo wwss iinn ee ss ss ,, hhaa lllluu cc iinn aa ttiioo nn ss ,, hh ee aa dd aa cc hh ee

CC VV:: A Ar r r r hh yytthh mmiiaa ss

GG II:: A Allttee r r ee dd ttaa ss ttee ,, bbllaa cckk ttoo nngg uu ee ,,

ccoo nn ss ttiipp aa ttiioo nn ,, dd aa r r kk ss ttoo oollss ,, dd iiaa r r r r hh ee aa ,, dd r r uu gg --iinn dduu ccee dd hh ee pp aa ttiittiiss ,, nn aa uu ss ee aa

GG UU:: DDee ccr r ee aa ss ee dd ss pp ee r r mm cc oo uu nn tt,, iimmpp oo ttee nn cc ee

EE NNDDOO :: GG yynn ee cc oo mmaa ss ttiiaa

HHEE MM A ATT:: A Agg r r aa nn uulloo cc yyttoo ss iiss ,, A App llaa ss ttiicc A Ann ee mmiiaa ,, nn ee uu ttr r oo pp ee nn iiaa ,, tthh r r oo mmbb oo cc yyttoo pp ee nn iiaa

LLOO CC A ALL::

A Ass ss ee ss ss pp aa ttiiee nn tt f f oo r r

ee pp iiggaa ss ttr r iicc oor r aa bb ddoo mmiinn aa ll pp aa iinn aa nn dd f f r r aa nn kk oor r oo cc ccuulltt bb lloo oodd iinn tthh ee ss ttoo oo ll,, ee mmee ss iiss ,, oo r r gg aa ss ttr r iicc aa ss pp iir r aa ttee ..

NN

uu

r r ss

ee

ss

hh

oo

uu

lldd

kk

nn

oo

ww

tthh

aa

tt iitt mmaa yy cc aa uu ss ee f f aa llss ee --

pp oo ss iittiivvee r r ee ss uu llttss f f oo r r uu r r iinn ee pp r r oo ttee iinn ;; ttee ss tt wwiitthh ss uu llf f oo ss aa lliicc yylliicc aa cciidd ..

IInn f f oor r mm pp aa ttiiee nn tt tthhaa tt iitt mmaa yy cc aa uu ss ee dd r r oo wwss iinn ee ss ss oo r r dd iizz zziinn ee ss ss ..

IInn f f oor r mm pp aa ttiiee nn tt tthhaa tt iinn cc r r ee aa ss ee dd f f lluu iidd aa nn dd f f iibb ee r r iinn ttaa kkee mmaa yy mmiinn iimmiizzee


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cc oo nn ss ttiipp aa ttiioo nn ..

A Add vviiss ee pp aa ttiiee nn tt ttoo r r ee pp oo r r tt oo nn ss ee tt oo f f bb llaa cc kk,, ttaa r r r r yy ss ttoo oo llss ;; f f ee vvee r r ,, ss oo r r ee tthh r r oo aa tt;; dd iiaa r r r r hh ee aa ;; ddiizz zziinn ee ss ss ;; r r aa ss hh ;; cc oo nn f f uu ss iioo nn ;; oor r hh aa lllluu cciinnaa ttiioo nn ss ttoo hh ee aa lltthh

cc aa r r pp r r oo f f ee ss ss iioo nn aa ll ppr r oo mmpp ttllyy..

IInn f f oor r mm pp aa ttiiee nn tt tthhaa tt mmee dd iicc aa ttiioo nn mmaa yy ttee mmpp oo r r aa r r iillyy cc aa uu ss ee ss ttoo oollss aa nn dd ttoo nn gguu ee ttoo aa pp pp ee aa r r

gg r r aa yy bbllaa cckk..

PP ee nn iicciilllliinn GG pp oo ttaa ss ss iiuu mm DDr r uu gg CCllaa ss ss

A Ann ttiibbiioo ttiicc PP ee nn iicciilliiiinn

A Ann ttiibbiioo ttiicc RR aa tt--bbiittee f f ee vvee r r DDoo ss aa gg ee

TTr r ee aa ttmmee nn tt oo f f ss ee vvee r r ee iinn f f ee ccttiioo nn ss cc aa uu ss ee dd bb yy ss ee nn ss iittiivvee oo r r ggaa nniiss mmss -- llee pp ttoo ttr r iicc hh iiaa bbuu cc cc aa lliiss ,, ss ttaa pp hh yylloo cc oo ccccii,,

pp nn ee uu mmoo cc oo cc cc ii,, NNee iiss ss ee r r iiaa gg oo nn oo r r r r hh ee aa

BBaa cc ttee r r iicc iidd aa ;;:: IInn hh iibb iittss ss yynn tthh ee ss iiss oo f f ccee llll wwaa llll oo f f ss ee nn ss iittiivvee

oo r r gg nniiss mmss ,, cc aa uu ss iinn gg ccee llll dd ee aa tthh ..

CC oo nn ttr r aa iinn ddiiccaa ttee dd wwiitthh aa llllee r r gg yy ttoo pp ee nn iicciilllliinn ss ,, ccee pp hh aa lloo ss pp oo r r iinn ,, iimmiipp ee nn ee mm,, bb ee ttaa --llaa cc ttaa mmaa ss ee iinn hh iibb iittoo r r ss ,, oo tthh ee r r aa llllee r r gg ee nn ss .. UUss ee ccaa uu ttiioo uu ss llyy wwiitthh r r ee nn aa ll

dd iiss ee aa ss ee ,, pp r r ee gg nn aa nn cc yy,, llaa ccttaa ttiioo nn ss

11 .. A Ass ss ee ss ss tthh ee pp aa ttiiee nn ttss hh iiss ttoor r yy ttoo aa llllee r r gg yy ttoo pp ee nn iicciilllliinn ss ,, cc ee pp hh aa lloo ss pp oor r iinn ss ,, iimmiipp ee nn ee mm,, bb ee ttaa --

llaa cc ttaa mmaa ss ee iinnhh iibbiittoo r r ss ,, oo tthh ee r r aa llllee r r gg ee nn ss ,, r r ee nn aa ll dd iiss ee aa ss ee ,, llaa cc ttaa ttiioo nn aa nn dd pp r r ee gg nn aa nn ccyy..

22 .. MMoo nn iittoor r iinn ttaa kkee aa nn dd oo uu ttpp uu tt.. DDee hh yydd r r aa ttiioonn


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dd ee cc r r ee aa ss ee ss dd r r uu gg ee xxcc r r ee ttiioonn aa nn dd mmaa yy r r aa iiss ee bblloooo dd llee vvee ll

oo f f pp ee nniicciilllliinn GG ttoo dd aa nn gg ee r r oo uu ss llyy hhiigg hh llee vvee llss cc aa uu ss iinngg kkiidd nn ee yy dd aa mmaa gg ee .. GG II dd iiss ttuu r r bb aa nn cc ee ss mmaa yy llee aa dd ttoo dd ee hh yyddr r aa ttiioo nn ..

33 .. CC uu llttuu r r ee iinnf f ee cc ttiioo nn bbee f f oo r r ee

bb ee gg iinn nniinn gg ttr r ee aa ttmmee nn tt;; r r ee ccuullttuu r r ee iif f r r ee ss ppoo nn ss ee iiss nn oo tt aa ss ee xxpp ee cc ttee dd .. ..

44 .. CC oo nn ttiinn uu ee tthh ee ttr r ee aa ttmmee nn tt f f oo r r 44 88--77 22 hh oouu r r ss aa f f ttee r r tthhee pp aa ttiiee nn tt iiss aa ss yymmpp ttoo mmaa ttiicc ..

55 .. MMoo nn iittoor r ss ee r r uu mm ee llee cc ttr r oollyyttee ss aa nn dd ccaa r r ddiiaa cc ss ttaa ttuu ss iif f pp ee nniicciilllliinn GG iiss gg iivvee nn bb yy IIVV iinn f f uu ss iioo nn.. SS oo dd iiuu mm oo r r pp oo ttaa ss ss iiuu mm pp r r ee pp aa r r aa ttiioo nn ss hhaa vvee bb ee ee nn

aa ss ss oo cc iiaa ttee dd wwiitthh ss ee vvee r r ee ee llee cc ttr r oollyyttee iimmbb aa llaa nn cc ee ss ..

66 .. KKee ee pp ee pp iinn ee pp hh r r iinn ee ,, IIVV f f lluuiidd ss ,, vvaa ss oo pp r r ee ss ss oo r r ss ,, bb r r oo nn cc hh oodd iiaa ttoo r r ss ,, oo xxyygg ee nn ,, aa nn dd ee mmee r r gg ee nn cc yy


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ee qq uu iipp mmee nn tt r r ee aa dd iillyy aa vvaa iillaa bb llee iinn cc aa ss ee oo f f

ss ee r r iioo uu ss hh yyppee r r ss ee nn ss iittiivviittyy r r ee aa cc ttiioo nn ..

77 .. IInn f f oo r r mm tthh ee pp aa ttiiee nn tt tthh aa tt tthh iiss dd r r uu gg iiss gg iivvee nn bb yy iinn j jee cc ttiioonn f f oo r r ss ee vvee r r ee iinn f f ee ccttiioo nn ss ..

88 .. UUss ee tthh ee ss mmaa llllee ss tt dd oo ss ee pp oo ss ss iibbllee f f oo r r IIMM iinn j jee cc ttiioonn ttoo aa vvooiidd pp aa iinn aa nn dd dd iiss cc oo mmf f oo r r tt..

99 .. A App pp llyy iicc ee ttoo r r ee lliiee vvee pp aa iinn ee xxpp ee r r iiee nn cc ee dd aa tt iinn j jee cc ttiioonn ss iittee f f oor r IIMM pp r r ee pp aa r r aa ttiioo nn ..

11 00 .. IInn ss ttr r uu cc tt tthh ee pp aa ttiiee nn tt ttoo r r ee pp oo r r tt aa nn yy uu nnuu ss uu aa ll bb r r uuiiss iinn gg ,, bbllee ee ddiinn gg ,, nn aa uu ss ee aa aa nndd vvoo mmiittiinngg ,, ss oo r r ee mmoo uu tthh ,, dd iiaa r r r r hhee aa ,, r r aa ss hh ,, f f ee vvee r r ,, dd iif f f f iiccuullttyy bb r r ee aa tthhiinngg ,, aa dd vvee r r ss ee ss iidd ee ee f f f f ee cc ttss ,, oo r r llaa cc kk oo f f iimmpp ..


19/22

::PP aa r r aa cc ee ttaa mmoo ll TTyyllee nn oo ll TTee mmpp r r aa PP ee dd r r iicc

FF ee vvee r r RR ee dd uu cc ttiioo nn ..

TTee mmpp oo r r aa r r yy RR ee lliiee f f mmiilldd ttoo mmoo dd ee r r aa ttee pp aa iinn

A Add uu lltt PP OO 55 0000 mmgg qq 44 hh oo uu r r

NNoo nn -- NNaa r r cc oottiicc A Ann aa llgg ee ss iicc PP r r oo dd uu ccee ss aa nn aa llgg ee ss iiaa bb yy uu nn kknn oo wwnn mmee cc hh aa nn iiss mm,, pp ee r r hh aa pp ss bb yy aa cc ttiioo nn oo nn pp ee r r iipphh ee r r aa ll

nn ee r r vvoo uu ss ss yyss ttee mm.. RR ee dd uu cc ee ss f f ee vvee r r bb yy dd iir r ee cc tt aa cc ttiioo nn oo nn hh yypp oo tthh aa llaa mmuu ss hh ee aa tt r r ee gg uullaa ttiinn gg ccee nn ttee r r wwiitthh ccoo nn ss ee qq uu ee nn tt pp ee r r iipp hh ee r r aa ll vvaa ss oo dd iillaa ttiioo nn ,, ss wwee aa ttiinn gg aa nn dd dd iiss ss iipp iiaa ttaa ttiioo nn oo f f hh ee aa tt BBaa cc ttee r r iicc iidd aa ;;::

IInn hh iibb iittss ss yynn tthh ee ss iiss oo f f ccee llll wwaa llll oo f f ss ee nn ss iittiivvee oo r r gg nniiss mmss ,, cc aa uu ss iinn gg ccee llll dd ee aa tthh ..

HHyypp ee r r ss ee nn ss iittiivviittyy ttoo aa cc ee mmiinn oo pp hh ee nn oo r r pp hh ee nnaa cc ee ttiinn

SS iidd ee ee f f f f ee cc ttss :: HHee pp aa ttiicc f f aa iilluu r r ee hh ee pp aa ttoo ttoo xxiicciittyy GG UU:: r r ee nn aa ll f f aa iilluur r ee ((hhiigg hh dd oo ss ee ss //cc hh r r oonniicc uu ss ee )) DDee r r mm:: r r aa ss hh ,, uu r r ttiiccaa r r iiaa

11 .. DDoo nn oo tt uu ss ee tthh iiss mmee dd iicc aa ttiioo nn wwiitthhoo uu tt

mmee dd iicc aa ll ddiir r ee ccttiioo nn f f oor r ::f f ee vvee r r pp ee r r ss iiss ttiinn gg lloo nngg ee r r tthh aa nn 33 dd aa yyss ,, f f ee vvee r r oo vvee r r 33 99 ..55 CC ((11 00 33 FF))oo r r r r ee cc uur r r r ee nn cc ee f f ee vvee r r

22 ..DDoo nn oo tt ss ee llf f mmee dd iicc aa ttee aa dd uullttss f f oo r r pp aa iinn

mmoo r r ee tthh aa nn 11 00 dd aa yyss wwiitthh oo uutt cc oo nn ss uu llttiinn gg aa pp hh yyss iicc iiaa nn

33 ..DDoo nn oo tt ttaa kkee oo tthh ee r r mmee dd iiccaa ttiioo nn ((ee ..gg .. ,, cc oo lldd ppr r ee pp aa r r aa ttiioo nn ss )) cc oo nn ttaa iinniinn gg aa ccee ttaa mmiinn oo pp hh ee nn

wwiitthh oo uu tt mmee dd iicc aa llaa dd vviicc ee ,, oo vvee r r dd oo ss iinn gg aa nn dd cc hh r r oo nn iicc uu ss ee ccaa nn cc aa uu ss ee lliivvee r r dd aa mmaa gg ee aa nn dd oo tthh ee r r ttoo xxiicc ee f f f f ee cc ttss


20/22


21/22

yy IInn f f uu ss ee f f oor r >>11 --44 hh oo uu r r ss gg iivvee nn

bb yy iinn ttee r r mmiittttee nn tt IIVV iinn f f uu ss iioonn ss ..

yy QQ uu ee ss ttiioo nn hh iiss ttoor r yy oo f f aa llllee r r ggiiee ss ee ss pp ee cc iiaa llllyy ttoo

ttee ttr r aa ccyycclliinn ee aa nn dd ss uullf f iittee ss ..

yy DDee ttee r r mmiinn ee pp aa ttttee r r nn oo f f bb oo wwee ll aa cc ttiivviittyy aa nn dd ss ttoo ooll cc oo nn ss iiss ttee nn cc yy..

yy

A Ass ss ee ss ss ss kkiinn f f oo r r r r aa ss hh .. yy MMoo nn iittoo r r llee vvee llss

oo f f cc oo nn ss cc iioouu ss nn ee ssss dd uu ee ttoo pp oo ttee nn ttiiaa ll iinn cc r r ee aa ss ee iinn iinn ttr r aa cc r r aa nniiaa ll pp r r ee ss ss uu r r ee ..

yy BBee aa llee r r tt f f oo r r ss iigg nn ss oo f f ss uu pp ee r r iinn f f ee cc ttiioo nn:: dd iiaa r r r r hhee aa ,, uu llcc ee r r aa ttiioo nn oo r r


22/22

cc hh aa nn gg ee ss oo f f oo r r aa ll mmuu ccoo ss aa ,,

aa nn dd gg ee nn iittaa ll pp r r uu r r iittuu ss ..

DDIICC LLOO FF EENN A ACC DDr r uu gg CCllaa ss ss

A Ann aa llgg ee ss iiss ,, A Ann ttii--IInn f f llaa mm mm aa ttoo r r yy,,

A Ann ttii--pp yyee r r ee ttiicc ,, NNSS A AIIDD,,

A Acc uu ttee oo r r lloo nn gg ttee r r mm ttr r ee aa ttmmee nn tt oo f f mmiilldd ttoo mmoo dd ee r r aa ttee pp aa iinn ,, iinn cclluu ddiinn gg dd yyss mmee nn oo r r r r hh ee aa

RR hh ee aa uu mmaa ttoo iidd A Ann tthh r r iittiiss A Acc uu ttee ttr r ee aa ttee mmee nn tt oo f f mmiigg r r aa iinn ee hh ee aa dd aa cchh ee oor r wwiitthh oo uu tt aa uu r r aa

OO ss ttee oo A Atthh r r iittiiss

IInn hh iibb iittss pp r r oo ss ttaa gg llaa nn ddiinn ss yynn tthh ee ttaa ss ee ttoo ccaa uu ss ee aa nn ttii--pp yyr r ee ttiicc aa nn dd aa nn ttii iinn f f llaa mm mmaa ttoo r r yy,, tthh ee ee xxaa cc tt mmee cc hh aa nn iiss mm iiss uu nn kknn oo wwnn

CC oo nn ttr r aa iinn ddiicc aa ttee dd wwiitthh aa llllee r r gg yy ttoo NNSS A AIIDDss ,, ss iigg nn iif f iiccaa nn tt r r ee nn aa ll iimmpp aa iir r mmee nn tt,, pp r r ee gg nn aa nn cc yy,,

llaa cc ttaa ttiioo nn .. UUss ee cc aa uu ttiioo uu ss llyy wwiitthh

iimmpp aa iir r ee dd hh ee aa r r iinngg ,, aa llllee r r gg iiee ss ,, hh ee pp aa ttiicc ,, CC VV,, GG II,, cc oo nn dd iittiioo nn ss ,, aa nn dd iinn ee lldd ee r r llyy pp aa ttiiee nn ttss

yy A Add mmiinn iiss ttee r r dd r r uu gg wwiitthh f f oo oo dd oo r r aa f f ttee r r mmee aa ll iif f GG II uu pp ss ee tt oo cc cc uur r ss

A Ar r aa nn gg ee f f oo r r oo pp tthh aa mmoo lloo ggiicc ee xxaa mm dd uu r r iinn gg lloo nn gg--ttee r r mm tthh ee r r aa pp yy

IInn ss ttiittuu ttee ee mmee r r gg ee nn cc yy

pp r r oo cc ee dd uur r ee iif f oo vvee r r dd oo ss ee oo cccc uu r r ss

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