An Evening Walk by the Sea Shore Essay Example for Free

An Evening Walk by the Sea Shore Essay After a hard day’s work, nothing is more refreshing than a quiet walk along the shore of the sea. While the exercise is good for our bodies, the presence of the ocean seems to have a pe ­culiarly tranquillizing influence upon our minds. Every sight and sound inspires a spirit of rest and peacefulness; and the effect is enhanced by the absence of the sights and sounds to which we have been exposed throughout the day. It is a delightful change, after escaping from the noisy bustle of our daily work, to hear the ceaseless music of the waves, and to breathe the fresh sea-breezes instead of the vitiated atmosphere of office or class-room. During our walk along the margin of the sea we enjoy the view of the broad expanse of waters spread out before our eyes, an unfailing source of delight to any one capable of appreciating the beauties of nature. For the ocean in all its changeful moods never ceases to be beautiful, and is especially beautiful at the hour of sunset. The spectacle presented by the setting sun, as it sinks beneath the ocean wave, is one of the greatest charms of an evening walk by the seashore. In India, for the greater part of the year, the clouds, whose fantastic shapes and brilliant hues add so much to the beauty of an English sunset, are wanting. But even in a cloudless sky when â€Å"the broad sun is sinking down, in his tranquility† and â€Å"the gentleness of heavens on the sea,† the spectacle presented to the eye is full of claim beauty. For some time after the sun has set, the sky is suffused with delicate tints of colour, until the first stars begin to appear on its darkening surface, and day finally gives place to night. In the beginning and the end of the monsoon we have splendid specimens of cloudy sunset, such as surpass the most vivid description given by En ­glish poets, and would, if faithfully depicted on canvas, be con ­demned as exaggerated representations of nature. At this time of year, while the evening sky is still of an intense blue, the clouds are tinged with gold, and purple, and all the colors of the rainbow, and the sea beneath repeats the brilliant coloring of the sky and the clouds above. From such a revelation of the beauties of nature the poor man derives as much pleasure as the choicest collection of paint ­ings and sculptures and other works of art affords to the million ­aire. Indeed, when we look with reverent awe upon the sea and sky at the hour of sunset, it does not seem  strange to us that the great powers of nature were once worshipped as gods; and the tranquillizing effect that the sea, especially in the evening, has upon the spectator, enables us to understand how the ancients found it natural to go to the shore and pour out their sorrows to the sea, when the hearts were overburdened with care and no mortal being seemed capable of giving consolation. Wordsworth, the great English poet, felt and beautifully expressed this in his sonnet beginning. â€Å"The world is too much with us,† in which he mourned the fact that most people had lost the power of appre ­ciating the beauty of nature, by giving themselves up to business and worldly pleasure â€Å"late and soon, Getting and spending we lay waste our powers.† He ends with this passionate outburst of desire for the old Greek love and reverence for nature. â€Å"Great God! I’d rather be A Pagan suckled in a creed outworn, so might I, standing on this pleasant lea, Have glimpses that would make me less forlorn; Have sight of Proteus rising from the sea; Or hear old Triton blow his wreathed horn.†

Case Study: Patient With Shortness Of Breath

Case Study: Patient With Shortness Of Breath Patient Identity The patient is a 54 year old female, Mrs SK who is a housewife with a BMI of 25.7kg/m2. Presenting Complaints She was brought in to the Accident and Emergency (AE) department, complaining of shortness of breath (SOB) and a productive cough. History of Presenting Complaints The patient was experiencing SOB for the past 2-3 days, and was progressively worsening on the day on admission. It was not associated with chest tightness and she was able to sleep the night before. She was also having persistent productive cough with white sputum since she was last discharged 12 days ago. Past Medical History She was diagnosed with diabetes mellitus and hypertension 8 years ago and has history of gastritis for the past 5 years. She was newly diagnosed with bronchial asthma in her last admission two weeks ago. Social History The patient is a widow since 6 years ago and is a housewife with 3 children. She stays in a factory area and has a cat at home. She is a non-smoker and a non-alcoholic. Family History Her mother and father have no known medical illness, but she has a cousin who suffers from bronchial asthma and is frequently admitted to the wards. Drug History The patient was on Salbutamol and Budesonide inhalers, 200mcg when necessary and 200mcg once at night respectively for her bronchial asthma. For her hypertension, she was on 40mg Telmisartan tablets once at night. She was also taking Gliclazide tablets, 80mg twice daily and Metformin tablets, 500mg three times a day for her diabetes mellitus. For her hypercholestrolaemia, the patient was taking Lovastatin tablets 20mg once at night. Based on the Morisky Scale, she was compliant with her medication and she had no known drug allergy. Examination Details On examination, the patient was alert and conscious. She was pink and appeared to be fairly hydrated. She was also able to speak in full sentences, and was not tachypnoeic. A Chest X-ray showed that there was a pneumonic consolidation at the right lower lobe of her lungs. Her blood pressure (BP) was 152/82mmHg, pulse rate (PR) was 109 beats per minute (bpm) and was afebrile. Her oxygen saturation (SpO2) was 96% under 3 litres of oxygen and her blood glucose was measured to be 4.7mmol/L. Investigations Upon admission, standard laboratory investigations were carried out and were obtained. From the renal function test, it was seen that the patient had a low potassium level of 2.8mmol/l and her calculated creatinine clearance was 60.0ml/min which indicated that she had mild renal impairment. The liver function test showed that she had normal liver function. The following shows the results that were out of the reference values for her haematological tests. C-Reactive Protein (CRP) 31.1 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Erythrocyte Sedimentation Rate (ESR) (0 15 mm/hr) 110 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Haemoglobin (Hb) (13.5-18 g/dl) 10.3 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Haematocrit (0.36-0.46 L/l) 0.303 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Red Blood Count (RBC) (3.8-4.8 x 1012 /l) 3.45 à ¢Ã¢â‚¬  Ã¢â‚¬Å" White Cell Count (WCC) (4-11 x 109 /l) 15.1 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Neutrophil (Neutro) (2 7.5 x 109 /l) 10.57 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Diagnosis/Impression Patient was initially diagnosed with Acute Exacerbation of Bronchial Asthma (AEBA) secondary to an upper respiratory infection (URTI) to rule out pneumonia. However, later in the day when the chest X-ray came back, she was diagnosed with pneumonia with right parapneumonic effusion. Management Plan The patients current medication was continued and was given 3 litres of oxygen via a nasal prong (NP). She was commenced on prednisolone tablets, 30mg once a day and was given nebulised Combivent (Ipratropium 20mcg/salbutamol 100mcg), every 4 hours. Her peak expiratory flow rate (PEFR) and SpO2 was to be monitored. Antibiotics were kept in view to be started if necessary after the total white blood count results came back. Clinical Progress Upon admission, the patient was afebrile, was tolerating orally well, did not have any sorethroat but was having a non productive cough. An echocardiogram (ECG) was done and it showed that she had sinus rhythm with no ischaemic changes. As her chest x-ray showed a right lower zone consolidation, she was diagnosed with pneumonia. She was immediately commenced on 2g Ceftazidime intravenously, and then continued on 1g three times a day. She was also under nebulised combivent every 6 hours. Her metformin and gliclazide was stopped and she was started on subcutaneous 10 units of Humulin  ® three times a day and 12 units of Humulin N once at night. On Day 2 of her stay, her blood results came back and as she has low potassium levels, she was given 15mls of Mist KCl three times daily and two Slow K tablets once daily. She was still complaining of cough without sputum and was given 15mls of Benadryl (diphenhydramine) syrup three times a day. The patient did not have any major complaints on the third day and was tolerating orally well. There was no SOB seen and she had good inhaler technique. She was then taken off the nebulizer combivent and the oxygen. By day 4, the patient was comfortable, and her cough and sputum had decreased. Examination on her lungs showed that she had prolonged expiratory phase. She was stopped on the Benadryl as well as Mist KCl and Slow K. After reinforcement on the inhaler technique by the pharmacist, the patient was discharged on day 5 as she was afebrile and had minimal cough. On discharge, she was then switched back to her oral hypoglycaemics and her intravenous antibiotic was switched to oral Cefuroxime 500mg twice daily for the next 10 days. She was also given Neulin SR 250mg once at night. Table 1 shows the vital signs chart for Mrs SK throughout her hospital stay. Table 1: Vital Signs Chart Day Time BP (mmHg) PR (bpm) SpO2 Blood Glucose (mmol/l) 1 13.00 178/102 109 100% 6.9 14.00 152/82 109 98% à ¢Ã¢â‚¬  Ã¢â‚¬Å" NP 15.40 4.7 18.40 133/73 114 97% à ¢Ã¢â‚¬  Ã¢â‚¬Å" RA 21.15 6.2 23.05 151/82 119 2 03.15 143/81 106 06.00 6.3 08.30 119/67 94 100% 10.35 4.8 11.24 100/61 107 97% 15.20 112/82 100 16.30 128/70 100 6.2 22.00 3.6 23.50 118/59 66 98%à ¢Ã¢â‚¬  Ã¢â‚¬Å"3L O2 3 04.10 124/64 104 100%à ¢Ã¢â‚¬  Ã¢â‚¬Å"3L O2 06.15 8.2 09.40 100/60 96 11.50 8.5 15.30 108/67 94 17.20 7.4 20.00 121/75 86 4 04.00 110/56 62 06.00 7.9 08.00 110/70 63 4.2 16.00 105/75 91 96% 17.00 9.7 22.00 138/67 114 6.1 5 05.00 9.6 07.15 11.1 Pharmaceutical Care Issues The first care issue is to review the management of AEBA based on the British Guideline on the Management of Asthma. The dose of prednisolone should be increased to 50mg once a day for at least 5 days or until recovery. Since the patient is prescribed with theophylline on discharge, she should be counseled on the signs and symptoms of theophylline toxicity such as confusion, dizziness, diarrhoea, nausea, fatigue and headache. The second issue is regarding the choice of antibiotics for the treatment of community acquired pneumonia in this patient. A sputum full examination microscopic examination (FEME) should be requested to identify the causative microorganisms of the lung infection. If empirical treatment is to be started the preferred drugs of choice would be amoxicillin 500mg three times a day plus either erythromycin 500mg four times a day or clarithromycin 500mg twice daily. Alternative choices would be levofloxacin 500mg once daily or moxifloxacin 400mg once a day, should the patient be intolerant of the preferred regimen. Thirdly, there is no clear indication of the prescription of the diphenhydramine in the first place, as it would only suppress the patients cough, which is inappropriate. Hence it should be stopped immediately. Next, the patients updated blood cholesterol levels should be taken and the appropriate use of statins should be reviewed. As she is on long-term statin use, her liver enzymes should be monitored regularly and if is raised by three-fold, she should stop taking the Lovastatin. She should also be counseled on the symptoms of rhabdomyolysis which is related to the long term use of statins, such as unexplained muscle pain, stiffness, weakness and the darkening of urine colour. The following issue is regarding the patients diabetes management. A HbA1c test should be done to determine her glycated haemoglobin level to see how well her self-management has been. She should also be advised on diet and lifestyle to keep her diabetes under control. Lastly, as she has low red blood count, haemoglobin and haematocrit levels, it is suspected that she has anaemia. Further tests should be done to confirm this, and if it is diagnosed, she should be given ferrous supplements such as ferrous sulphate tablets 200mg twice daily. DISEASE OVERVIEW AND PHARMACOLOGICAL BASIS OF DRUG THERAPY Acute Exacerbation of Bronchial Asthma: An Overview Asthma is a chronic inflammatory disorder of the airways where many cells and cellular elements play a role. This leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the morning. These inflammatory symptoms are commonly associated with extensive but variable airflow obstruction within the lung as well as airway hyperresponsiveness and this is reversible either on its own or with treatment. 1 Asthma is a worldwide problem as it is estimated that about 4.5% of the worlds population is affected, which amounts to 300million individuals approximately. The global prevalence of asthma varies from 1-18% of populations in countries all over the world. Asthma has three distinguishing characteristics which are airflow limitation, airway hyperresponsiveness, and bronchial inflammation. Airflow limitation is usually resolved by itself with or without treatment but for individuals with chronic asthma, inflammation may result in irreversible airflow limitation. Stimuli such as irritants or allergens may pose as triggers in airway hyperresponsiveness and bronchial inflammation is associated with eosinophils, T-lymphocytes and mast cells which cause plasma exudation, smooth muscle hypertrophy, mucous plugging and epithelial changes. It is shown that inflammation of the airways play a major role in the pathology of asthma and this starts when allergens or irritant trigger the activation of cells such as epithelial cells, macrophages, lymphocytes and mast cells. This leads to cytokine or mediator release and smooth muscle contraction resulting in cellular infiltration of eosinophils and neutrophils causing airway inflammation including oede ma, epithelial permeability or injury, mucous secretion and vascular permeability which eventually leads to airway obstruction and hyperresponsiveness. The diagnosis of asthma is based on a collection of signs and symptoms without a reasonable explanation for them and spirometry is an early test which is easy to assess if there is any airflow obstruction present and its extent. For diagnosed patients with asthma, acute exacerbations may occur and because patients with severe asthma are at increased risk of death following exacerbations, assessments of exacerbations are crucial. Clinical features of acute asthma exacerbations include severe breathlessness, tachypnoea, tachycardia, silent chest, cyanosis, or syncope. Peak Expiratory Flow (PEF) or Forced Expiratory Volume in one second (FEV1) is also used to measure the lung capacity. Oxygen saturation (SpO2) is measured using a pulse oximetry and this aids oxygen therapy as oxygen therapy is given in order to keep SpO2 levels at 94-98%. Measurements of arterial blood gases (ABG) are usually not necessary unless patients present with features of life-threatening asthma or have SpO2 of less than 92% as there may be a risk of hypercapnea if SpO2 is lower than 92%. Chest X-rays are also not recommended unless patients are suspected of pneumonia or lung consolidations, suffering from life-threatening asthma, having unsatisfactory response to treatment or if they require ventilation. Pharmacological Intervention in the management of AEBA2 Oxygen Oxygen therapy is needed most of the time as patients who are having acute asthma usually present with hypoxia as well. Hence, all patients with hypoxia who are suffering from acute severe asthma should be given oxygen and their SpO2 levels should be kept at 94-98%. ÃŽÂ ²2 agonist bronchodilators As first line therapy, high dose inhaled ÃŽÂ ²2 agonist bronchodilators are used as soon as possible as rapid relievers of bronchospasm. For patients who are unable to use inhaled therapy, intravenous ÃŽÂ ²2-agonists are used instead. ÃŽÂ ²2 agonist bronchodilators work by stimulating the ÃŽÂ ²2 adrenoceptors in the lungs, thus causing relaxation of the airways. Examples of short acting ÃŽÂ ²2-agonist are salbutamol and terbutaline, and a long acting ÃŽÂ ²2-agonist is salmeterol. Glucocorticosteroids Steroids should always be given in all cases of acute asthma. Examples of these are prednisone, prednisolone, dexamethasone, and hydrocortisone. They exert an anti-inflammatory effect by inhibiting transcription of the genes for the cytokines implicated in asthmatic inflammation and hence reduce airway hyper-responsiveness. Anti-cholinergic agents Ipratropium bromide is one of the anti-cholinergic agents that is used widely in treatment of acute exacerbations of asthma. Nebulised ipratropium bromide is used in combination with a ÃŽÂ ²2-agonist bronchodilator as treatment for patients with severe acute or life-threatening asthma. Anti-cholinergic agents work by inhibit muscarinic receptors M1 and M3 which then reduces cGMP formation and decreases smooth muscle contractility in the lungs. This eventually results in bronchodilation and reduces mucus secretion. Other therapies Other therapies include the use of magnesium sulphate. A single bolus dose of intravenous magnesium sulphate is administered to patients with acute severe asthma with previous unsatisfactory response to inhaled bronchodilator therapy or for patients who are suffering from life-threatening or near fatal asthma. It is believed that magnesium sulphate works by reducing calcium uptake by the bronchial smooth muscle cells, causing bronchodilation and also inhibits mast cells degranulation, thus reducing the release of inflammatory mediators such as histamines, and leukotrienes. EVIDENCE FOR TREATMENT OF THE CONDITION The management of asthma can be divided into two parts; acute treatment, and long term management. Management of acute asthma It has been shown that most patients suffering from acute severe asthma are hypoxaemic. Therefore it is essential that supplementary oxygen therapy be given to them.3-6 This is administered via a face mask or nasal prong with the patients SpO2 kept between 94-98%.7 Where nebulisers are needed in therapy, oxygen-driven nebulisers are favoured instead of those that are air-driven due to oxygen desaturation when driven by air alone.8-10 However, the lack of provision of supplemental oxygen should not pose as a factor in omitting nebulised therapy from administration if deemed appropriate.11 Referring to the case presented above, the patient was treated accordingly as she was immediately given supplemental oxygen and her SpO2 was maintained well above 96% throughout hospital stay. As acute asthma is associated with symptoms of bronchospasms such as wheezing and tachypnoea, the main aim of treatment is to quickly resolve these symptoms and most often, high doses of inhaled ÃŽÂ ²2 agonist bronchodilators are effective with minimum adverse effects.12-14 Salbutamol is usually the drug of choice although there is no significant differences in terms of efficacy as compared to Terbutaline. It is shown that there are no significant clinical benefits by using a non-selective ÃŽÂ ²2 agonist such as epinephrine instead of selective ÃŽÂ ²2 agonists.15 Based on a meta-analysis, it is seen that ÃŽÂ ²2 agonists administered via inhalation are more preferable and has similar efficacy with those administered intravenously in adult acute asthma.16 In ventilated patients or those in life-threatening conditions, parenteral ÃŽÂ ²2 agonists may be added to inhaled ÃŽÂ ²2 agonist treatment although there is little evidence supporting this treatment. Although a sing le bolus nebulisation may relieve most acute asthma cases, it is shown that continuous nebulised treatment of ÃŽÂ ²2 agonists is more effective in relieving acute asthma for those with unsatisfactory response to initial therapy.17, 18 Steroid therapy is always given in acute exacerbations of asthma and it is proven that it has better result if given earlier. It not only reduces mortality but it also reduces relapses and the number of hospital admissions as well.19, 20 Oral steroids given are seen to be equally as effective as parenteral treatment hence there is no need for the use of parenteral administration of steroids unless the patient is unable to tolerate orally.19 Prednisolone 40-50mg is given daily for at least five days or until recovery and this can be stopped abruptly after the patient has recovered.2 As long as the patient is on inhaled steroids, there is no need for the dose to be tapered down slowly prior to discontinuation.21 In the case presented, the patient was commenced on steroid therapy but was under-treated as she was only given prednisolone 30mg once daily for just one day. Hence, there is a need to increase the dose of prednisolone to 50mg and to continue is for at least another four days or until recovery before stopping this treatment. In hospital therapy, anticholinergic treatments are given to severe exacerbations of asthma and nebulised ipratropium bromide is always the drug of choice used in clinical settings. A combination of nebulised ipratropum bromide with a ÃŽÂ ²2 agonist bronchodilator is often given as treatment as it is proven that a combination of these two agents has a significant increase in bronchodilatation as compared to the use of a ÃŽÂ ²2 agonist alone. Hence, there is faster recovery and will reduce the length of hospital stay. However, it is also seen that anticholinergic treatment is not particularly effective and favourable for cases of mild exacerbations of asthma as well as after the patient has been stabilized, thus is not necessary in these cases.22-24 The patient in this case was seen to be having a mild exacerbation of acute asthma and hence nebulised ipratropium bromide treatment was not necessary. However, the use of nebulised Combivent, a combination of ipratropium bromide and salbutamol was justified since this patient was re-attending with a relapse and she was also suffering from pneumonia as well. Hence, there was probably a need for a quicker rate of bronchodilation as well as faster recovery for her. The use of magnesium sulphate in hospital treatment of AEBA is not widely seen, however there have been some evidence showing the bronchodilating effects of magnesium sulphate when used in adults.25 There are also studies which report that nebulised magnesium sulphate combined with a ÃŽÂ ²2 agonist shows positive outcomes and good clinical effectiveness in hospital settings.26, 27 The use of an intravenous bolus administration of magnesium sulphate is believed to promote lung function in patients who have severe asthma without harmful side effects.28 Nevertheless, there have been no studies on the repeated administrations of magnesium sulphate, though it is presumed that repeated use may lead to hypermagnesaemia, causing muscle weakness and respiratory failure. As further extensive studies need to be done to determine the most suitable route and dosing of magnesium sulphate, this treatment is reserved only for patients with acute severe asthma without satisfactory response to inha led bronchodilator therapy and patients with life-threatening of near fatal asthma. Monitoring should be carried out constantly throughout hospital stay and in acute asthma cases, monitoring of PEF is crucial. PEF readings should be measured and recorded every 30 minutes after treatment has been started. PEF should also be monitored pre- and post- nebulisation therapies as long as the patient is in hospital and until the asthma is well under control after discharge. It is seen that after hospital discharge, a relative amount of patients either experience relapse or are readmitted into the hospital with at least 15% within two weeks following discharge.29 Therefore it is essential that patient education such as proper inhaler technique, and well-documented PEF recordings with action plans depending on symptoms experienced should be instilled in order to reduce rate of relapses as well as minimize problems associated with exacerbations after discharge.30 Monitoring of the patients PEF was done consistently throughout her hospital stay and the patient was given sufficient counseling prior to discharge on her inhaler technique. However, there was no evidence that the patient was educated on self-documenting PEF recordings as well as action plans based on symptoms experienced following discharge and this should be done in this case to avoid another exacerbation of her condition. Long Term Management of Asthma The aim of management of asthma is to keep it well-controlled without the need of rescue medications, asymptomatic, no exacerbations, no hindrance to daily activities including exercise as well as normal lung function. A stepwise management approach is adopted for asthma patients and this is to acquire initial control and maintain it by stepping up treatment to improve control if necessary or stepping down treatment if there is good control over the condition to maintain the lowest step that will control the patients condition. As the patient is currently on regular preventer therapy with inhaled steroids, she is currently on step 2 of the management of asthma. There have been many studies being carried out to compare the different inhaled steroids that are being used for asthma and it is shown that beclomethasone diproprionate and budesonide are both similarly clinically effective although there may be different devices for delivery. It has also been seen that fluticasone and mometasone being administered at half the dosage of beclomethasone and budesonide shows equivalent clinical effectiveness, however there is somewhat inadequate evidence that fluticasone possesses fewer side effects and further studies need to be carried out on establishing the safety profile of mometasone.31 A new inhaled steroid has been introduced which is ciclesonide and clinical trials have shown evidence that it has more local activity than systemic and less oropharyngeal side effects as compared to the regular inhaled steroids.3 2-35 Although this seems promising, this clinical advantage is still controversial as its safety to efficacy ratio has yet to be established and compared with the conventional inhaled steroids. Inhaled steroids are recommended as preventer drug therapy for adults as they are most clinically effective in controlling asthma based on the treatment goals outlined.36-39 The frequency of dosing of inhaled steroids are generally twice daily and it is shown that there is slight clinical benefit obtained when taken twice a day than once daily, however a once daily dosing may suffice for those with milder asthma. There is also limited evidence of advantage with increased frequency of greater than twice a day.37 In addition to that, starting at higher than recommended doses have no significant effectiveness in management of mild to moderate asthma.40 Hence the recommended dosage for inhaled steroids would be 200-800mcg daily. This would be an add-on therapy to the step 1 management of using in haled short acting ÃŽÂ ²2 agonist bronchodilator as required. Based on the presented case, the patient was on budesonide 200mcg once at night prior to admission but this was immediately increased on admission and was in line with the recommended guidelines as she was continued on budesonide 400mcg twice a day together with salbutamol 200mcg as required following discharge. Other preventer therapies may be included for the patient despite inhaled steroids being the first choice of drugs for preventer therapy. These alternatives are less effective although they have shown some clinical benefit in patients who are on short acting ÃŽÂ ²2 agonists only. Chromones which act as mast cell stabilizers such as sodium cromoglicate and nedocromil sodium have shown to be beneficial in adults.41, 42 Apart from that, leukotriene receptor antagonists montelukast and zafirlukast too have clinical benefits.37, 43, 44 Theophylline also have some evidence in showing benefits in adults.36, 45 The patient in the case presented above was prescribed sustained-release theophylline on the last day of admission. Although it is another option that may be added to daily controller medications for step 2 management, there is very little evidence on the clinical efficacy of it as a long term controller. There is no reason to justify the use of theophylline in this case as the patient is responsive and can be controlled on inhaled steroids. Further more, theophylline has a narrow therapeutic index and close monitoring of plasma theophylline levels is necessary because at concentrations above 25 µg/ml, there is high risk of tachycardia and seizures may occur if concentrations exceed 35 µg/ml. CONCLUSION After reviewing the management of the patients condition throughout hospital stay, it can be concluded that SK was treated adequately based on the current guidelines and evidences attainable. She was given all necessary treatment at point of admission and there was no lacking of medications in all four days of her hospital admission. Apart from that, monitoring of her condition was carried out consistently and all data was updated, leaving no room for questioning and doubt. However, there were a few issues that came to attention which were the prescribing of several drugs that were unnecessary such as diphenhydramine and theophylline. There were little and no clear evidence that these drugs prescribed would be of benefit to the patient, and may also increase the risk of harmful effects to her as well. Alongside treatment of her acute condition, SKs controller medications were reviewed and subsequent changes were made as appropriate. Besides that, her other co-morbidities were also managed well as treatments for her hypertension and diabetes mellitus were given accordingly. PATIENT MEDICATION PROFILE PATIENT DETAILS Name S.K. Consultant Dr YKS General Practitioner Address Gender Female Weight 65kg Height 1.59m Community Pharmacist Date of Birth (Age) 54 years old Known Sensitivities NKDA Social History Widow of 6 years, Housewife, Non-smoker, Does not drink PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date 17/04/09 Shortness of breath for the past two days, progressively Discharge Date Discharged to 21/04/09 Home worsening today and productive cough. RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments 2001 Diabetes Mellitus T. Diamicron 80mg BD 2001 Hypertension T. Metformin 500mg TDS 2004 Gastritis T. Telmisartan 40mg ON 2009 Bronchial Asthma MDI Salbutamol 200mcg PRN MDI Budesonide 200mcg ON T. Lovastatin 20mg ON RELEVANT NON DRUG TREATMENT Prescribed Medication Start Stop Clinical/Laboratory Tests Date Result 1 T. Telmisartan 40mg OD 18/04 21/04 2 T. Gliclazide 80mg BD 17/04 17/04 3 T. Metformin 500mg TDS 17/04 4 T. Lovastatin 20mg ON 17/04 19/04 5 MDI Salbutamol 200mcg 2 puffs PRN 17/04 6 MDI Budesonide 200mcg 2 puffs BD 17/04 7 T. Prednisolone 30mg OD 17/04 17/04 8 Neb. Combivent 6-hourly 17/04 19/04 9 IV Ceftazidime 2g STAT, then 1g TDS 17/04 21/04 10 S/C Humulin R 10units TDS 17/04 21/04 11 S/C Humulin N 12units ON 17/04 21/04 12 Syrup Diphenhydramine 15mls TDS 18/04 20/04 13 T. Slow K 2tabs BD 18/04 20/04 14 Mist KCl 15mls TDS 18/04 20/04 15 T. Theophylline 250mg OD 20/04 CLINCIAL MANAGEMENT Diagn

Humorous Wedding Speech from the Father of the Bride -- Wedding Toasts

Humorous Wedding Speech from the Father of the Bride Well, good afternoon everyone, for those of you that don?t know me my name is Lee and I?m Janie?s dad, and in keeping with tradition, it is my honor and privilege to deliver the ?Father of the Bride Speech?. Having to make this speech is one of the few opportunities in a married man?s life when he is allowed to do all of the talking...and I intend to make the most of it. Now, giving a speech can be a little stressful so I will put into practice what I preach, that is...always remember the ABC to the XYZ of public speaking. ABC..Always Be Confident, ?XYZ..Xamine Your Zipper. (check zipper). It won?t be a long speech on account of my throat?.no, it?s not sore, it?s just that Janet threatened to cut it if I go on too long! So I?ll start...Distinguished guests, those of dubious distinction and those of absolutely no distinction whatsoever, family, relatives, friends, relatives of friends, friends of friends, hotel staff, freeloaders and hangers-on, on behalf of Janet and myself, I extend a warm welcome to Janie and Martin?s wedding celebration reception. You know, delivering the ?Father of the Bride? speech feels a bit like a sheikh walking into his harem for the first time...you know what to do, but you don?t know where to start. I will start however by taking this opportunity to thank especially Janet for not only being chief worrier and organise... ... we marry. It is very obvious that they have found in one another a perfect match; their happiness shines like a beacon. Janie and Martin, there is no challenge in a marriage that cannot be overcome by the following three, three word sentences: I was wrong. You were right. I love you. So, approaching the toast, ladies and gentlemen, please stand and make sure your glasses are fully charged?mine is being charged to Barclaycard? Janie and Martin? Here?s to the past for all that it taught you Here?s to the present for all that you share And here?s to the future for all that you can look forward together Ladies & gentlemen please raise your glasses. The toast is?Janie & Martin, Bride and Groom

Fact vs. Fiction in the Movie (Film), Jurassic Park :: Movie Film Essays

Fact vs. Fiction in the Movie (Film), Jurassic Park In Steven Spielberg's Jurassic Park, dinosaurs come to life on the big screen for audiences' worldwide.   Millions have watched this film, but what number of them have halted to wonder at the truth behind the story?   How many have stopped to think whether the dinosaurs are portrayed correctly within a scientific aspect?   Unbeknownst to many, there are a number of mistakes in Spielberg's film regarding the dinosaurs, from how they were recreated to their common names. One prominent flub that is witnessed throughout the duration of the film, besides the fact that most of the dinosaurs are from the cretaceous period, is the fact that it remains impossible to bring dinosaurs back to life.   Dinosaurs are extinct!   They have been extinct for 65 million years.   True, one would need dinosaur DNA to recreate dinosaurs, and it is indeed possible for mosquitoes with the DNA of dinosaurs to have been trapped in hardening amber, as seen in the film.   However, it is impossible for scientists today to find hardened amber with dinosaur DNA in it, simply because DNA does not last; it degrades over time (even in preserved amber).   Just the tiniest bit of degradation would ruin its value (UCMP 1995).   Therefore, you would not have the starting point for proceeding with such an endeavor as the scientists inaccurately accomplish in Spielberg's film: the breeding of dinosaurs. Continuing on with the amber, the film claims that it was discovered in a Dominican mine.   Dominican amber mines are scientifically aged at the Miocene and Oligocene epochs (French 1998).   These epochs take place later than 65 million years ago, roughly from 38 to 5 million years ago, which in turn means that dinosaurs were most likely not around when this specific amber was formed.   Remains of dinosaurs have only been found from the Triassic, Jurassic, and Cretaceuos periods, from 251 to 65 million years ago. Another fact of fiction in this film involves the truly terrifying velociraptors.   These specific dinosaurs are nicknamed "raptors", a name that now refers to the entire family of dinosaurs, not just the velociraptor as indicated in the film.   In science before the film, the name "raptor" identified birds of prey.

What Governments Are Not Essay -- essays research papers

;What Governments Are "Not" In this essay I will be comparing the three economic systems: Communism, Capitalism and Socialism and will explain differences and similarities along with illustrations of each system. Communism is an economic system where the government owns and operates the means of production and distribution. It is also known as a command system because individuals cannot succeed others, the government controls all. Capitalism is an economic system where private individuals own and operate the means of production and distribution. People have the freedom to own, choose, compete and earn a living but with little or no government help. They have the freedom to own, choose, compete and earn a living. Socialism is a mixed market economic system. The basic means of production is managed and owned by the government, with the public owning and operating many businesses. Cooperation is stressed over competition, goals are high standard of living and economic security and high taxes provide free health care and education. In communism the government controls the market while in capitalism private individuals own and control the market. Socialism is a mix of the two because the government owns and controls production but with public owning and operating many businesses. In all three systems the lack of competition hurts the quality of goods and profits go down. So...

Benefits of Returning to School

The many benefits to returning to school and some of the obstacles I had and have to overcome to see my dream come alive. What I want to see happen and by faith it’s going to happen. | I have many reasons for returning to school. I had the chance to get a job in television station, and have never done television before and wanted to at least have a general idea of what would be expected to do this job. First thing that came to my mind about going back to school I didn’t know if I would be able to do the work. I had been out of school so long would I remember the simple things, was scared and didn’t know if or how I would be able to maintain, but with the grace of God I’m doing it. The first couple classes to me was like a refresher, because I had been out of school for so long once I saw the work it all came flooding back. Plus, I wanted to start my own business and what better way to have a successful business than to know everything there is to know before you jump in to deep. I would have to say the benefits of my degree would be seeing single parents like me with goals and dreams and no one to help them fulfill them. With no one to even watch their children, while they try to attempt to start the process. Seeing single parents smile when they have the help that is needed to gain a better life is enough for me. If I just gave up and let the Devil win I wouldn’t be able to help those in need. Everything from computer problem to no lights, and I still made a way. I live by faith and there is nothing better that knowing that the Lord Jesus Christ got my back through it all, and willing to make a way for me to see my dream come alive. Helping other people is what I want to do in life. Single parents will be my main focus, helping them find the benefits they will need to assure their families are stable. I have always been kindhearted, and wanted to help people. What other way than to keep someone from going through what I had to alone. My life style has changed so much I’m more spiritual, open minded, and more aware of the many road blocks along the way. If I can help at least one family it would warm my heart and that would be enough for me. I have been where a lot of people are and at the same time not knowing that the next person may be going through something more serious than I. So what’s more fulfilling than to help ones that feels like me, over come some of the obstacles I had to, to make a better life for their children. The many obstacles I had to overcome just to start my degree were very overwhelming early in the process. First day class started my computer crashed, had to get another one since it was early on in the process I was able to start over. Next, my internet service stops working. Then in to the program once everything was back on track second class my new computer wants to stop working, couldn’t access the portable document formats. If it wasn’t one thing it was something else. I was determined to get my degree, by any means necessary, neighbors house, friends houses, libraries, anywhere where there was an internet connection I was trying to get there. My number one strategy for overcoming the many obstacles is prayer and that’s how I plan to get through the rest of my degree. A wise man once said, â€Å"No weapons formed against me shall prosper; and every tongue that shall rise against thee in judgment thou shall condemn. This is the heritage of the servants of the Lord, and their righteousness is from me, Says the Lord† (Isaiah 54:17 KJB). Plus I can do all things through Christ who strengthens me (Philippians 4:13 KJB). I also know that whatever God does it shall be forever. Nothing can be added to it, and nothing taken from it (Ecclesiastes 3:14 KJB). Everything I do in life these days I pray and ask the Lord to show me his way. Like with this paper, I really don’t know how to write a good paper. When I sat down after I wrote the first draft and started typing it parts of it changed. I worked hard and hope it shows and pray it’s the way it was suppose to be done. I don’t see any more obstacles that are too much for me not to get my degree. I feel that if it took this much hard work to get something I really want then it will be will worth the fight. I fight everyday, willing and ready for what else the devil has to put in my way. I can honestly say that the hard work that comes alone with my degree will be well worth it once I have that piece of paper with my name on it.

American Film Revised

If one were to sit up and pay attention to Jon Lewis' American Film: A History, they would realize that the history of American cinema is not merely a linear progression of historically significant dates or landmark moments, but a story in which history shaped the motion pictures and motion pictures shaped history. Like history, the story of cinema is not a dead thing – an easily understood as the story of artifacts left behind, but a story in which relationships bring things to the surface.Film is shaped by history as it chronicles the fears and hopes of an era, and its zeitgeist, just as it skews and re-frames, like any other form of artistic expression, our perception of our own history. In Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb (1964) director Stanley Kubrick makes satirical work of Cold War geopolitics by hypothesizing an absurdly inadvertent nuclear attack. Kubrick and his screenwriters also milk the material for a good puerile laughs by dep icting war imagery as a series of comical psycho-sexual symbols.While the film was produced and released at a time when few outspokenly criticized geopolitical thinking, its timeliness has accorded it a relevance that cannot be said for similar war satires produced in later decades. Contrast that with D. W. Griffith's The Birth of a Nation (1915), a politically charged interpretation of post-Civil War events. Unlike Strangelove, it was produced a whole five decades after the events it depicts. The Birth of a Nation functions as historical retrospective – conjuring up a period-based narrative openly hostile to the African-American people.Griffith's film rejects the notion that black people could ever be integrated into the civilized Aryan world by portraying them as savage Other infiltrating respectable white living. One novel form of historical signficance is the referential motion picture, which gives topical emphasis on film making itself. This is best exemplified by Singin g in the Rain (1952) in which glamorous star Lina Lamont's voice proves to be utterly unappealing for the ears and hearts of potential moviegoers and gets dubbed over by voice Kathy Seldon, an under-employed chorus girl.A historical picture in its own right, Singing in the Rain is set in the period after Jazz Singer (1927) brought sound to the movies, and gives audiences a comical look at the awkward transition from silent pictures to talking features in the late 20s. Other films, like Blade Runner (1982) are historical in how they hypothesize the future. It would be a mistake to call the film a majestic exercise of futuristic prognostication. Instead, it functions as a historical document by examining present concerns and where they may go if they continue their course into tomorrow.A rather uncomplicated romance mystery involving synthetic humans infiltrating Earth, Blade Runner examines society's xenophobia towards immigrants while contrasting it against an ironic reliance on tec hnology. All this happens in Los Angeles, 2019 – where the world is highly globalized, politically corporatized and environmentally devastated. Presenting history in film is also a means to reconcile the neuroses of individuals, if not generations with past events. Using advanced technology, director Robert Zemeckis revises history to assuage the boomer generation's discomforts in Forrest Gump (1994).A low IQ simpleton manages to stumble his way into just about every important event in American history from the 50s to the 80s. Armed with nothing but good old Southern morals, he survives three decades of social tumult in America while his self-aware peers succumb to AIDS, war injuries and other sorts of misfortune. History is smoothened out by digital technology, allowing a static view of history to prevail: one where the survivors never question their assumptions about the ways of the world.