Nastradamus Essays - Nostradamus, Divination, Pseudoscience

Nastradamus Michel de Nostredame otherwise known as the latinized name Nostradamus. Was born on December 14th, 1503 in St. Remy, France and was educated by his grandfather, Jean. Which he was taught mathematics and astrology. Also was taught three languages which include Latin, Greek, and Hebrew. Nostradamus was the oldest son of his family and had four brothers. Nostradamus was a physician in France during a time that many plagues invaded the country. Not many things were known about Nostradamus' early life except that he was homeschooled by his grandfather. In most of Nostradamus' adult life he was trying to help many French people who were infected by some of the plagues that invaded France at that time. Nostradamus did in fact go to school to get a bachelor's degree for medicine in 1532. Nostradamus is also known for being an astrologer which he did not receive a degree for, although there is no facts that he was a good or famous astrologer of his time, many people do mention that in their w ritings. Nostradamus is most famous for his book Centuries that he wrote in cryptic four line quatrains. Nostradamus does not have many accomplishments, but you could call his most famous prophecies his accomplishments because they were heard around the world. The prophecy that started his fame was one, which he predicted that the king of France would die in an accidental death. Four years later King Henri II was pitted against the count in a jousting tournament. Later on, angry mobs burned Nostradamus because of his psychic abilities. Amazingly enough, he managed to escape the mobs and continued in the completion of his book. One of Nostradamus' predictions that are thought to be the most famous is his prediction of world revolution. In his book Centuries it states, ?In the year 1999 and seven months, from the sky will come the great terror king. He will return the life of the great Mongol king. Before and after warfare happily rules.? The date that he states at the beginning is Au gust 1999. In August 1999 it is said that there will be a cross of the planets in the signs relating to the four beasts of the Apocalypse- Taurus the bull, Scorpio the scorpion, Leo the lion, and Aquarius the man. Astrologers believe that stress of this grouping could generate extreme violence, unrest, and natural catastrophe. A prediction that Nostradamus made in his book that many people now a days are scared of is the end of the world. He supposedly predicted that the end of the world would happen somewhere near the year 2000. Most of the time people do not believe Nostradamus' prophecies until they actually happen. At this point the majority of the world does not believe Nostradamus. Many people know of Nostradamus as just a famous prophet, but he had do have a job to bring in money just like the rest of us. He did put his education in medicine to good work; he treated many plagues that invaded France during the 16th century. He was also noted for being an astrologer to clients who included the Queen of France. He studied the stars and maybe he might have found one of the constellations. He once received a letter from Julius-Cesar Scaliger. Apparently Nostradamus' reply was so pleasing to Julius that he invited him to stay at his home in Agen. There, Nostradamus married a young girl of high estate. Supposedly she was very beautiful and admirable. Her name is not available but they did have a son and daughter. Unfortunately a plague came to Agen and killed his wife and two kids. He did infact, try very desperately to sane the three of them but his efforts did not work. Shortly after that tragedy he quarreled with Julius and lost his friendship. He also did produce a yearly almanac called The Prognostications, which he started sometime after 1550. Unfortunately this famous seer had to die some time; the bright side of this tragedy is he was not assassinated. There is not an exact date or even an estimation on the day Of his death, but he was buried upright in the walls of the

Microsoft Office Essays - Presentation Software, Free Essays

Microsoft Office Essays - Presentation Software, Free Essays There are many ways Microsoft Office, which include-Microsoft Word, PowerPoint, and Excel, can help me in my future career. Not knowing how to use widely-used products could greatly hinder my chances at success. These tools can make many different tasks and projects simple and easy. Think back of how hard it was just two decades ago to do presentations like we do today using PowerPoint. PowerPoint presentations have made it so we can make our point of view appealing to a wide range of people with minimal effort. Excel has made doing all sorts of organizing tasks so much easier, and the wide range of tasks it supports is indeed numerous. Microsoft word has made writing documents and letters in business format so much easier. And more accessible from a click of a button. Microsoft Office is the most widely-used productivity suite in the world and thats not for nothing. It tends to work. Of the millions that own the software however, a scarce few are probably fully aware of what power lay beneath their fingertips. (Boundless, 2014). Try thinking back to two decades ago, if anyone had an idea for a new product or a new way to do business and wanted to present this what would they have done? In order to do a presentation on this, the task would have been an overwhelming one. With only some writing material- pens, pencils, paper, and a typewriter- one would have been required to make a presentation on the various subjects. One of the only means that is like PowerPoint would have been a screen projector, which is rather makeshift compared to the PowerPoint we have today. With PowerPoint I can add facts, pictures, graphics, and sounds that make the presentation look very professional and fun. Microsoft Excel is a program that is found within the Microsoft Office Suite of computer programs that are meant to make life easier for both individuals as well as businesses of all sizes. Excel has a wide range of useful functions like spread sheets for almost everything that requires organization! Making different charts, graphs, budgets, and much more (Ruparel, 2014). Excel allows me to unlock the potential of my data, by using formulas across a grid of cells. I can use pie charts, graphs and clustered columns to add meaning to data, which otherwise may just exist as row after row of numbers. References Ruparel, A. (2014, August 07). 5 Key Uses of Microsoft Excel in the Workplace. Retrieved from learn.filtered.com: http://learn.filtered.com/blog/5-key-uses-of-excel-in-the-work-place Source: Boundless. The Advantages and Disadvantages of PowerPoint. Boundless Communications. Boundless, 14 Nov. 2014. Retrieved 01 Apr. 2015 from https://www.boundless.com/communications/textbooks/boundless-communications-textbook/preparing-and-using-visual-aids-16/using-powerpoint-and-alternatives-successfully-85/the-advantages-and-disadvantages-of-powerpoint-323-5654/

Discussion Essay Example | Topics and Well Written Essays - 250 words - 98

Discussion - Essay Example Second, is caste immobility wherein moving from one caste to another is extremely rare. However, if a person has exceptional skills that are rare in the society, he or she can ascend to a higher caste of professionals (McMahon 1). People in the higher caste hold the political power, and within the caste, people are subdivided further under language, economic, and cultural aspects. Each member within a caste knows his or her place within the caste (N.D). The caste system is a culture practiced in many societies, though; the most known caste system is the Indian system. The Indian caste system is based on the Hindu religious scriptures; though, it is practiced in other religions. Each caste, in India, has its own rules and customs. The social orders are arranged in ranks with the first order being Brahmans that consists of priests and professionals. The second caste comprises the Kshatriyas, who include rulers and warriors. The third comprises the Vaishyas who are associated with traders. The forth is the Shudras, the laborers. A group of other people not included in the four castes exists, the untouchable. The untouchable do menial jobs, such as garbage collection that made the society regard them as the impur e ones (The US History Organization

Materials Engineering Project Research Paper Example | Topics and Well Written Essays - 1250 words

Materials Engineering Project - Research Paper Example This paper has also discussed the different applications of titanium alloys and its limitations in different uses in the modern society. Introduction Titanium alloy is a metal that consists of mixture titanium as the main element and other elements. This is done to achieve high toughness and tensile strength. Generally, alloys have extreme temperature resistance, resistance to corrosion and yet they are light in weight. The process of Titanium Alloying involves the allotropic transformation of pure titanium to the cubic beta phase at very high temperatures of 882.50C (Joshi, 2006). Elements used for alloying normally act as stabilizers at beta or alpha phase. However, by using alloying additions, it is possible to have alpha phase coexisting with beta phase at room temperatures. This is the principle behind manufacture of titanium alloys that can withstand high temperatures during heat strengthening. Titanium alloys are classified into three major groups; beta alloys, alpha alloys an d alpha-beta alloys. Alpha is formed by addition of neutral alloying materials as well as alpha stabilizers such as Sn and Aluminum & Oxygen respectively. Beta alloys on the other hand contain enough beta stabilizers that enable such alloys to retain their beta phase even after quenching. The strength of beta alloys can also be increased through subjecting them to solution treatment and aging. The third category of titanium alloys is beta-alpha alloys that contains both beta and alpha stabilizers thus withstand heat treatments at various degrees. It is important to note that the nature of alloy and stabilizers used greatly influence the heat stability, toughness, tensile strength and other mechanical properties. Production of Titanium Alloys Kroll Extraction Process Titanium alloy is made from Titanium metal and other chemical elements. The main production process for titanium metal is called Kroll process. It involves treatment of the main ore known as rutile with chlorine gas in o rder to get a compound known as Titanium tetrachloride. This compound is then purified and reduced by sodium or magnesium to produce metallic titanium sponge. It is the Titanium sponge that undergoes several alloying process that involve heating and melting to produce Titanium Alloys. In this respect, the purity of titanium resulting from Kroll process is therefore critical for alloying process. According to Leyens & Peters (2003), the purity of titanium Produced depends on the purity of the starting material as well as the parameters and treatments. His is because there are several metallic elements that may cause very undesirable impacts even when they are present in small amounts. Melting Process The second stage in the production of titanium alloys is the melting process. Melting process involves combination of extracted Titanium alloy with alloying elements depending on the type of alloy to be produced. There are about five melting processes: induction Skull melting, vacuum arc remelting, plasma arc melting, Electroslag refines and Plasma Arc melting Process (Joshi, 2006). Melting process begins by blending together alloying elements with sponge followed by hydraulic pressing necessary to produce excellent blocks known as briquette. Apart from sponge, other titanium from scroll process such as scrap or Revert can also be used depending on the quality of the final Titanium Alloy

Nurse-to-Patient Ratio Research Proposal Example | Topics and Well Written Essays - 2000 words

Nurse-to-Patient Ratio - Research Proposal Example However, this factor is never considered when nurses are assigned to care for a selected number of patients. Quoting Barbara Blakeney, President, American Nurses Association (ANA), the American Association of Critical Care Nurses (AACN) endorses the fact that inadequate nurse staffing is the primary concern for the nurses and that â€Å"when RN care is insufficient, patient safety is compromised and the risk of death is increased† (Nurse-to-Patient Ratios, 2007). Shortage of nurses places extra onus on the available staff and hence seasoned nurses are matriculating away from bedside nursing. This happens primarily because the added tasks needed to be performed are not directly related to patient care. This can be evidenced in the case of Cameroon Diva, a BSN, who states that she wants to quit bedside nursing because in the hospital where she has worked, they had â€Å"extreme staff shortage and not enough nursing assistance on the floor† (Diva, 1996). Besides, the frequ ent changes in computerized charting require nurses to remain near their computers and take their time away from the primary task of patient care. It is a matter of common knowledge that higher patient-to-nurse ratios cause significant physical and mental exhaustion and result in greater job dissatisfaction among nurses. Patient well-being directly correlates to the amount of nursing care a patient receives daily. Therefore, in order to achieve the objective of providing quality patient care, administrators and managers need to ensure that healthcare institutions attain an appropriate level of patient-nurse ratio. Problem Statement: Current policy on Medical-Surgical nursing units across America’s hospitals require that Registered Nurses care for five to six (average of â€Å"5.25†) acutely and chronically ill patients in a 12 hour shift (Welton, 2007). Licensed practical nurses also care for 6 to 7 patients during a 12 hour shift. Nurses feel that added tasks take awa y a considerable portion of their time, which otherwise can be spent on patient care. The diversification in the roles of nurses today, through deployment on other tasks, calls for a closer examination of the need to change the policy pertaining to nurse–to-patient ratios. In this context, the findings of Aiken et al can be perceived as the â€Å"primary arguments for setting specific nurse-to-patient staffing ratios† (Welton, 2007). There is a definitive discrepancy between what healthcare administrators believe to be adequate the level of nurse-patient ratio and actual number of patients a nurse is required to care for. This creates impediments in administering proper care to the needy patients, which, in turn, impacts patient mortality rates. Besides, the shortage in staffing also adversely affects the job satisfaction of nurses and, as a consequence, their rate of burnout increases. Purpose of the Study: The purpose of this study is to determine whether there exist s a correlation between nurse-to-patient ratios and patient mortality. The number of patients cared for by a single nurse may have better outcomes in terms of length of hospital stay and fewer complications. Additionally, nurses who derive satisfaction from their jobs are less likely to leave their jobs. The study will also investigate the increasing trend of nurse burnout and find

Case Summary Hypertension In Pregnancy Health And Social Care Essay

Case Summary Hypertension In Pregnancy Health And Social Care Essay Mdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is at 37 weeks and 5 days of gestation. She was diagnosed to have hypertension in pregnancy during antenatal routine follow-up in Klinik Kesihatan Simpang Renggam at 36 weeks and preeclampsia (blood pressure 160/100mmHg, urine dipstick albumin 1+) 3 days before admission. She was admitted to Hospital Kluang and started on Tab. Methyldopa 250mg TDS. She was advised for induction of labour in view of preeclampsia at term and she requested to be transferred to Hospital Batu Pahat (HBP). She did not have any signs and symptoms suggestive of severe preeclampsia or labour. During admission to HBP, tablet prostin 1.5mg was inserted into the posterior fornix twice to induce labour but there was no change in cervical os and symptoms of labour. Decision was made to try artifical rupture of membranes. However, following the procedure, internal monitoring detected fetal distress and as spontaneous delivery was not imminent, Mdm. S M was agreeable for emergency lower section caesarean section under general anaesthesia. A healthy infant boy was delivered (weight 2.9kg, Apgar score 91105) and there were no intra or post-operative complications. Following the surgery, both mother and infant were well in the ward. Mdm. SM was ambulating and tolerating orally and by the 2nd post-op day, both had passed urine and motion. Wound inspection on day 2 showed clean, non-gaping wound. As she was well, decision was made to discharge her and she was given appointment to review her blood pressure and operative wound at the postnatal clinic at KKSR. On discharge, her blood pressure was 140/70mmHg (without medication) and urine dipstick albumin was trace. Analgesia given on discharge were mefenemic acid and paracetamol. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology PATIENTS DETAILS I/C NUMBER: 800318015794 AGE: 30 SEX: Female DATE OF ADMISSION: 20/6/2010 R/N: 1358593 2) CLINICAL HISTORY Chief Complaint Elevated blood pressure detected in pregnancy at 36 weeks of gestation. History of Present Illness Mdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is currently at 37 weeks and 5 days of gestation. She was referred to Hospital Kluang from Klinik Kesihatan Simpang Renggam (KKSR) for elevated blood pressure detected on routine antenatal follow-up and subsequently transferred to Hospital Batu Pahat (HBP) for induction of labour in view of her development of high blood pressure in pregnancy. Her elevated blood pressure was first detected during her routine antenatal follow-up at Klinik Kesihatan Simpang Renggam 10 days before admission to HBP. During this visit, her blood pressure was recorded as 150/90mmHg and she also complained of slight bilateral swelling of her feet but otherwise had no other complaints. The feet swelling resolved after 3 days. Throughout the next 7 days, she went to KKSR every alternate day for monitoring and 3 days before admission to HBP, her blood pressure was noted to be 160/100mmHg with presence of albumin 1+ on urine dipstick that was prev iously not present. She was immediately given tablet labetolol 100mg and admitted to Hospital Kluang where she was subsequently started on tablet methyldopa 250mg 8-hourly. Three days after admission to Hospital Kluang, she was advised by the doctor to undergo induction of labour and she thus requested to be transferred to HBP so her family members in Batu Pahat could take care of her. During the course of these events, she did not experience shortness of breath, headache, blurring of vision, epigastric pain, seizures, abdominal pain, vaginal bleeding, nausea, vomiting, palpitations, or recurrence of the foot swelling. At time of admission, she did not experience contraction pain, show, leaking of liquor. Fetal movements were good. Systemic Review Mdm. SM did not have fever. Her appetite was good and her urinary and bowel habits were normal. Her sleep was unaffected. Antenatal History This was an unplanned but wanted pregnancy. Mdm. SM realized she was pregnant when she missed her period, of which the last was 28/12/09. She bought a pregnancy test kit and it tested positive. She subsequently did her booking at KKSR at 7 weeks of period of amenorrhoea. At booking, her blood pressure was 120/80mmHg, hemoglobin 13.4g/dL, sugar undetected, and urine albumin negative. Infective screening was negative and blood type O positive. Her expected due date was given as 14/8/10. During follow-up 1 month later, she had her first ultrasound scan which found her uterus to be larger than dates. Her due date was revised to 6/7/10. Modified glucose tolerance test done twice during pregnancy were negative. She experienced morning sickness and vomiting during the first 3 months of pregnancy but it was not severe and she could cope without medication. Throughout the pregnancy, she was diagnosed to have urinary tract infection twice and was treated with antibiotics. A further 3 ultrasoun d scans were done and all were normal. She was also compliant to the supplements given throughout pregnancy. There were no other problems during the antenatal follow-up until the detection of elevated blood pressure 10 days before admission to HBP. Past Obstetric History This is her fifth pregnancy and her last childbirth was in 2008. She has 3 children, 2 boys and a girl, of whom all were born via vaginal delivery at postdate after induction of labour. Birth weights ranged from 2.7 to 3.0kg, all are healthy with no complications and were breastfed. However, during her 3rd pregnancy, she suffered a miscarriage during the 12th week and dilatation and curettage was performed during that admission. Gynae Menstrual History Mdm. SM achieved menarche at the age of 12. Her menstrual cycles have always been regular with 28 days per cycle and 5 to 7 days of flow. She does not experience menorrhagia or dysmenorrhoea. She has never had a cervical smear done and has never used oral contraceptive pills. She has not required medical attention for any gynaecological problem. Past Medical History Mdm. SM has never been diagnosed with any chronic disease such as diabetes, hypertension, and asthma before. She has also never been admitted for non-pregnancy related reasons. She also does not have any known food or drug allergies. Family History Mdm. SM is the eldest of three siblings. Her youngest sister also had gestational hypertension. Her father has hypertension and her mother had diabetes, but passed away 2 years ago due to tuberculosis. All family members have been screened and all tested negative for tuberculosis. Social History Mdm. SM is now a housewife. She formerly worked in a factory but decided against returning to work following her last pregnancy in 2008 for her childrens benefit. She is a non-smoker and does not consume alcohol. Her husband is a short-haul lorry driver and smokes, but only outside their home. They live slightly off Kluang, and it takes them slightly over an hour to reach HBP, and 15 minutes to reach KKSR. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 3) FINDINGS ON CLINICAL EXAMINATION (Mdm. SM was examined by me on the 2nd day of admission) Mdm. SM was alert, conscious and cooperative. She was not in any pain or distress. She was sitting comfortably on her bed. On examination, there was no pallor, jaundice or pedal edema. Her reflexes were not brisk. Her clinical parameters are: Blood Pressure : 124/80 mmHg Heart Rate : 95 beats per minute. Regular rhythm Respiratory Rate : 20 breaths per minute Temperature : 37 °C Examination of the cardiovascular system, respiratory system, fundus, thyroid and breasts were normal. On examination of the abdomen, it was distended with gravid uterus as evidenced by linea nigra, and striae albicans. There was no striae gravidarum, scars, or pulsations noted. On palpations, the abdomen was soft and non-tender, uterus non-irritable, and fetal parts felt. The symphysio-fundal height was 36cm, which corresponds to dates. On examination, this is a singleton fetus at longitudinal lie with cephalic presentation, with the fetal back on the maternal left. The fetal head was four fifths palpable. Estimated fetal weight is 2.8 to 3.0kg. Liquor is adequate. Fetal heart was heard and the rate was 142 beats per minute. Vaginal examination (by medical officer on admission) revealed no perineal, vulval or vaginal abnormalities. Cervical os was 1 cm with cervix tubular, soft and axial, station high and membrane intact. Bishops score was 3/10. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional Diagnosis Preeclampsia in pregnancy Mdm. SM developed new onset elevated blood pressure of 160/100mmHg at 36 weeks of gestation and urine dipstick albumin of 1+ (300mg/L). This fits the minimum requirement of preeclampsia among the hypertensive diseases in pregnancy. However, Mdm. SM did not experience any symptoms to suggest a severe preeclampsia or impending eclampsia such as headache, visual disturbances, epigastric pain, vomiting, liver tenderness. The urine dipstick for albumin is not the best way to detect proteinuria required for the diagnosis of preeclampsia 3 and is usually only used for screening, but as the blood pressure and urine albumin were persistently elevated, it is better to err on the side of caution and treat Mdm. SM as such since patients with relatively mild preeclampsia can rapidly progress into severe disease 1. Following the repeated positive detection of urine albumin of only 1+, more definitive tests should be performed to better quantify her proteinuria 2,3. Differential Diagnosis Pregnancy-induced hypertension, late onset As Mdm. SM has been compliant to her antenatal follow-ups and did not have elevated blood pressure detected at any time before 36 weeks of gestation, it is likely that she has developed the onset of a hypertensive disease in pregnancy and it appears to be of late onset as it developed only after 32 weeks gestation. However, as subsequent visits showed urine dipstick albumin of 1+, indicating the onset of proteinuria (although poor predictive value and not as significant as 2+) 3, it might prove wiser to be more vigilant and assume that Mdm. SM does indeed have preeclampsia as it would be foolish to dismiss these warning features despite the fact that she does not demonstrate any suggestive symptoms because it is possible that even patients with no prodromal signs may suddenly progress into eclampsia 1,3. Essential hypertension in pregnancy with superimposed preeclampsia Another possibility that we may entertain is that Mdm. SM has had previously undiagnosed essential hypertension with currently superimposed preeclampsia. However, this seems rather unlikely. Firstly, Mdm. SM is young at the age of 30 and unlikely to suffer from essential hypertension as this disease common presents after the age of 40. Secondly, at no time throughout antenatal follow-up did she have elevated blood pressure recorded before that particular visit at 36 weeks of gestation. However, following delivery of her infant, she should have her blood pressure rechecked during postnatal follow-up care at 6 to 12 weeks post-delivery. If her blood pressure if still elevated at that time, then it will be more likely that she has essential hypertension. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Elevated blood pressure and its implications in pregnancy Mdm. SM has newly discovered elevated blood pressure at 36 weeks of gestation. This is considered late onset but is not uncommon, and gives rise to a spectrum of hypertensive disorders in pregnancy. While it seems that at first she has gestational hypertension, the mildest of the disease spectrum, she demonstrated proteinuria on her subsequent antenatal visit, therefore concluding that she has preeclampsia. Hypertensive disorders in pregnancy have the potential to put both mother and infant at increased risk of mortality. Its complications are elaborated below. During admission, Mdm. SM should be monitored for any change in her condition as she may quickly progress into severe disease states and this would require urgent intervention, the most definitive being the delivery of the infant. Ward management includes close observation of both mother and infant, and medication to control the elevated blood pressure. 2. Induction of labour in view of preeclampsia at term Termination of the pregnancy is the only definitive sure for preeclampsia. On presentation, Mdm. SM has features categorized as mild preeclampsia. Normally, severe preeclampsia would dictate the need for antihypertensive and anticonvulsive therapy followed by subsequent delivery and symptoms such as headache, epigastric pain, and visual disturbances may indicate this. The fetal age is usually an important deciding factor when it comes to inducing labour as the treatment goals seek the best outcome for both mother and infant. As Mdm. SM is already at term and there have been no issues previously detected regarding the health of her fetus, it should be safe to proceed with induction of labour. There is also no reason to prolong the pregnancy as the risk of eclampsia increases. If for any reason an obstetric reason arises e.g. fetal distress, delivery should proceed via caesaren section. 3. Impending eclampsia and other potential complications Warning signs and symptoms of impending eclampsia or severe preeclampsia include headache, visual disturbances, epigastric pain, reduced urine output, edema and ultimately, convulsions. These symptoms should be recognized early so the necessary intervention can take place. Seizures increase the risk of maternal and perinatal morbidity and mortality rates. Some maternal complications are placenta abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, and acute renal failure. Other major complications that may occur as a result of severe preeclampsia are HELLP syndrome, pulmonary embolism and stroke. Fetal complications include growth restriction, fetal distress, and death. 4. Risk of post-partum eclampsia It is possible for eclampsia to occur in the postpartum period especially when the patient has reached term. In such cases, up to 44% of eclampsia occurs postpartum 3. As the risk is quite high, Mdm. SM should continue to be monitored in the ward for the development of any signs and symptoms. As she is comfortable and relatively symptom free while in the ward, it appears unlikely that she may worsen into an eclamptic state but the risk should not be afforded. As there are no guidelines to suggest an optimum postpartum inward observation period, it would depend on her clinical situation during the subsequent days following her delivery. 5. Hypertension in pregnancy and its long term implications As Mdm. SM has developed preeclampsia during this pregnancy, she is at increased risk to develop hypertensive or metabolic complications in future pregnancies. The risk of recurrence is generally higher in earlier onset preeclampsia. At the same time, she should be evaluated in the postpartum period for the possibility of essential hypertension at the 6 week postnatal review. Also, women with preeclampsia are at an increased risk for developing hypertension, diabetes, hyperlipidemia, chronic renal disease, stroke and ischemic heart disease. Mdm. SM should be made aware of all these implications and should be educated on how she can prevent these via the modification of her lifestyle. She should also be advised to attend preconceptual counseling in the event of a future pregnancy and to come early for booking. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1. Urine Dipstick for Albumin To look for the presence of albumin in the urine firstly, to confirm proteinuria, and secondly, to evaluate the severity of the preeclampsia. Urine dipstick for albumin should be repeated daily in the ward. Also, if in doubt, further investigation to quantify proteinuria can be done e.g. urine protein/creatinine spot test 2,3. Results: Urine dipstick albumin on admission was trace. Results at KKSR showed 1+. Interpretation: This result could be due to the fact that the blood pressure has lowered as Mdm. SM has been started on methyldopa and her blood pressure is under control. This does not mean that she no longer has preeclampsia. She should be checked daily for any changes in both blood pressure and proteinuria. 2. Full Blood Count To look for anemia which may require correction, haemoconcentration which may indicate severe preeclampsia 1, and platelet levels as HELLP syndrome is a complication that may arise in preeclampsia. This may also serve as baseline in case operative procedures are required. Result: TWBC 12.0 x109/L à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ (neutrophils 8.20, lymphocytes 2.70) Hemoglobin 10.7 g/dL à ¢Ã¢â‚¬  Ã¢â‚¬Å" Hematocrit 32.3% à ¢Ã¢â‚¬  Ã¢â‚¬Å" Platelets 354 x 109/L Interpretation: The total white cell count is slightly raised, but this is to be expected in pregnancy. The hemoglobin is slightly low but this is also expected in pregnancy and should be monitored especially if the patient requires surgery or experiences anemic symptoms. There is no haemoconcentration and the platelets are normal. 3. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT) To obtain a baseline of the coagulation profile in case operative procedures are required and also to look for potential coagulopathy as it is a possible complication of preeclampsia. Result: PT 12.3s INR 1.05 APTT 39.6s Interpretation: PT/INR/APTT is within normal range. Coagulopathy appears unlikely in Mdm. SM given that her platelets are also normal and her preeclampsia is not severe. 4. Renal Profile To assess renal functions to look for elevation of creatinine as that would indicate severe preeclampsia and also to detect acute renal failure which is associated with increased risk of HELLP syndrome, placenta abruption and postpartum hemorrhage 1. Result: Urea 1.3mmol/L Sodium 140mmol/L Potassium 3.7mmol/L Creatinine 51 µmol/L Interpretation: Mdm. SM renal profile is normal and creatinine is not elevated, adding to the indicators that her preeclampsia is of the mild category. Low urea levels and good urine output also rules out acute renal failure. 5. Liver Functions Test To assess liver functions and its components such as liver enzymes and bilirubin which would be raised in severe preeclampsia or HELLP syndrome in which there is hemolytic anemia and elevated liver enzymes. Result: Total protein 73g/L Albumin 33g/L Globulin 40g/L Total bilirubin 0.5mg/ml Direct bilirubin 0.2mg/ml Indirect bilirubin 0.3mg/ml ALP 121U/L à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ ALT 7 U/L GGT 7 U/L Interpretation: Liver enzymes (ALT) and bilirubin levels are not elevated, indicating a mild preeclampsia and no biochemical evidence of HELLP syndrome. The ALP is slightly elevated, but this could be due to compression of the gravid uterus on the hepatobiliary tree. 6. Serum Uric Acid Elevated serum uric acid is an early biochemical sign of preeclampsia 1 and may help to predict maternal complications in preeclampsia 4. Results: Serum uric acid 103 µmol/L à ¢Ã¢â‚¬  Ã¢â‚¬Å" Interpretation: Serum uric acid levels are not elevated and are in fact, slightly lowered. This result indicates low likelihood of severe preeclampsia or maternal complications. 7. Serum Lactate Dehydrogenase To check for elevated levels which should indicate hemolytic anemia, a component of HELLP syndrome. Results: Not done during this admission. 8. Cardiotocograph (CTG) Done on admission as a baseline for fetal monitoring. Results: Baseline fetal heart rate was 130 beats per minute, baseline variability was 5 10, accelerations present with no decelerations. Interpretation: CTG is reactive with no signs of any fetal compromise. CTG should be repeated following each procedure e.g. prostin insertion, AROM or if fetal compromise is suspected. 9. Transabdominal Ultrasonography This should be done to confirm fetal age, as confirmation of fetal age is important when it comes to deciding whether or not to induce labour in preeclampsia. Also to check for fetal well-being and growth restriction, but these requires repeated scans and plotting of growth chart over a period of time. Result: No ultrasonography was done during this admission. The last scan was done in Hospital Kluang before patient was transferred to HBP. The last scan reports fetal age corresponding to dates, AFI of 9, and no abnormalities detected with no mention of other findings. Interpretaion: As fetal age is corresponding to dates and there is no suggestion of fetal compromise or restriction, it is safe to proceed with induction of labour. 10. Urinalysis (UFEME) To check the levels of proteinuria which may be more quantitative than urine dipstick. Results: Leukocytes, nitrite, protein, glucose, ketone, urobilinogen, and bilirubin were not detected. Interpretation: No proteinuria was detected. This could mean that the patient does not have preeclampsia but rather gestational hypertension, or it could be undetected as the blood pressure has also become well controlled with medication. However, no risks should be taken and Mdm. SM should be closely observed in the ward. Either way, induction of labour and delivery would still be ideal for her as she has already reached term. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working Diagnosis Induction of labour at term in view of mild preeclampsia in pregnancy Comment: As Mdm. SM has elevated blood pressure and urine dipstick albumin 1+ but has no physical or biochemical features suggestive of severe preeclampsia, the working diagnosis is mild preeclampsia. However, she should be monitored closely in the ward for any symptoms indicative of disease progression. As she has reach term, it would also be wise to induce labour in her, especially given her history of postdates as delivery would be the only definitive management in such cases. Plan of management on admission Continue T. Methyldopa 250mg 8-hourly Daily urine albumin dipstick Vital signs monitoring 4-hourly Baseline cardiotocograph on admission Fetal kick charting and Labour progress charting To notify immediately if spontaneous rupture of membranes To notify immediately if strong contractions commence Encourage orally For induction of labour with T. Prostin 1.5mg as Bishops score unfavourable To notify immediately if any symptoms occur STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES) Throughout the first two days of admission, Mdm. SM was comfortable in the ward with no development of any symptoms of severe preeclampsia, eclampsia, or labour. Her vital signs were stable with blood pressure ranging 122-138/70-84. On the morning of the 2nd day, tablet prostin 1.5mg was inserted into her posterior fornix under aseptic technique. Cardiotocograph was reactive and vaginal examination 6 hours post-insertion showed cervical os 3cm, cervix 2cm, soft and axial, and high station. Therefore, a 2nd tablet of prostin was inserted on the morning of the 3rd day. Once again, post-insertion cardiotocograph was reactive and vaginal examination 6 hours later showed no changes to before. Mdm. SM still did not experience any signs and symptoms of labour. She also did not have any symptoms indicating progression of her preeclampsia. On the morning of the 4th day, it was decided that Mdm. SM should undergo artifical rupture of membranes (AROM) rather than have a 3rd prostin tablet inser ted. Cardiotocograph monitoring had been difficult so decision was made to insert fetal scalp electrode at the same time for internal monitoring. Following the AROM, internal monitoring revealed a drop of fetal heart rate from 130 to 100 beats per minute with no accelerations. Cervical os was still 3cm with no symptoms of labour. Decision was made to proceed with emergency lower section caesarean section (ELSCS) under general anaesthesia and Mdm. SM gave her consent. Via ELSCS, a healthy baby boy was delivered weighing 2.9kg with Apgar score of 91105. There were no intra or post-operative complications. Post-operative medications given include IV ampicillin 500mg QID, subcutaneous heparin 5000 units BD, IV pitocin 40 units QID, IM pethidine 50mg PRN, Tab. paracetamol 1g QID and Tab. Mefenemic acid 500mg TDS. Throughout the next 2 days, Mdm. SM was comfortable in the ward and had mild operative site pain with no other symptoms and vital signs were stable. All medications except analg esia were stopped. She was ambulating well, tolerating orally and had passed urine and motion by the 5th day. As for the baby, breastfeeding had commenced and he had also passed urine and motion. The uterus was well contracted at 22 weeks size and dressing was not soaked. Inspection of the wound on the 6th day revealed a clean and non-gaping wound. She was counseled on contraception and indicated a preference for intrauterine contraceptive device. As she was well, she was discharged with appointment to return to postnatal clinic at KKSR to review her blood pressure and operative wound in 1 weeks time. On discharge, her blood pressure was 140/70mmHg and urine dipstick albumin was trace. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge Plan Tab. Mefenemic acid 500mg TDS PRN Tab. Paracetamol 1g QID PRN Follow-up appointment at Klinik Kesihatan Simpang Renggam (KKSR) Postnatal clinic in 1 week to review blood pressure and operative wound. Follow-up appointment at KKSR in 6 weeks for review, cervical smear, and contraception. Counseling Advised to return immediately to the hospital if Mdm. SM has problems with the caesarean wound e.g. pain, discharge or if she develops any new or worrying symptoms. Advised on the need to be compliant to postnatal follow-up to review Mdm. SMs condition. Advised for cervical smear during postnatal follow-up as previously never done. Counseling regarding breastfeeding and contraception. Explain about the nature of pregnancy-related hypertensive disorders and its long term implications. Advised to attend antenatal clinic for preconceptual counseling if future pregnancy is desired, or to come for booking immediately once discovered to be pregnant. Advised to observe a healthy lifestyle in order to prevent development of conditions such as hypertension and diabetes. Mock Prescription Tab. Paracetamol 1g QID PRN x 1/52 Tab. Mefenemic acid 500mg TDS x 1/52 STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 10) REFERRAL LETTER (IF APPLICABLE) Medical Officer, Postnatal Clinic, Klinik Kesihatan Simpang Renggam, 86200, Simpang Renggam. 20th June 2010 Mdm. SM (IC.800318015794) Date of admission: 20th June 2010, Date of discharge: 25th June 2010 Problem: Late onset hypertensive disease in pregnancy Dear medical officer, Mdm. SM is a 30-year-old Malay lady of parity 4+1 who was diagnosed to have preeclampsia at 36 weeks of gestation during routine antenatal follow-up at your centre. During admission to our ward, she underwent induction of labour with tablet prostin and artificial rupture of membranes. However, fetal distress developed, picked up on internal monitoring and Mdm. SM underwent emergency lower section caesarean section under general anaesthesia. She delivered a healthy baby boy (2.9kg, Apgar 91105) with no complications intra- and post-operatively. We are discharging her into your care. Please review her blood pressure as scheduled and also offer contraception and cervical smear as previously never done. She has indicated preference for intrauterine contraceptive device. Do not hesitate to contact us immediately should the need arise. Thank you very much for your attention. Yours sincerely, Paul Kong Fu-Xiang (Final year medical student, IMU), Department of Obstetrics Gynaecology, Hospital Batu Pahat. STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129 NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics Gynaecology 11) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1. Disease prevention and health promotion Hypertensive disorders in pregnancy are one of the most common antenatal problems and eclampsia is a major source of maternal mortality. What are the ways in which some element of prevention can be instituted or to decrease the severity of preeclampsia? There haven been certain strategies touted to prevent or modify the severity of preeclampsia. These are categorized as dietary supplements, antihypertensive medications, antioxidants, and antithrombotic agents 5. As low salt diet is one of the recommended dietary changes for hypertensive patients, De Snoo et al 1 was one of the earliest researchers to study the effects of low salt diet in preventing preeclampsia but this practice was discarded as it yielded no significant change. Knuist et al performed a randomized controlled trial in 1998 and they reported that despite helping control blood pressure in non-pregnant individuals, a sodium-restricted diet was ineffective in 361 women in terms of prevention of preeclampsia 6. The dietary supplementation of calcium of at least 1 gram per day is recommended as class I-A evidence 2. Several studies showed that women with low calcium diets were at significantly increased risk of gestational hypertension 7,8,9. Levine et al performed a large , randomized-controlled trial and they found that there was no significant difference in outcome with calcium supplements versus placebos 10. This suggests that unless a pregnant woman has a low calcium intake, calcium supplements may have no added benefit 5. With regards to fish oil supplements and its cardioprotective fatty a

Critique of Story Haircut :: essays research papers

Reading through the whole story "Haircut" , it is not easy to believe that the death of Jim Kendall is really accidental. It is most likely that the incident is a murder. Jim Kendall is not a man who is loved by people in that small town, although some people find his jokes funny as long as they are not on them. There are many examples of those on whom Jim always makes annoying jokes such as Milt who "has got an Adams apple that looks more like a mushmelon" Julie Gregg and especially Paul Dickson who fell out of a tree when he was about ten years old : "Lit on his head and it done something to him and he ain’t never been right. No harm in him, but just silly." Paul is the most important one among them because of two reasons: He is not as clever and reasonable as the others and he is the one who was killed Jim Kendall. Of course these do not prove that the killing of Jim is on purpose. However there are some more reasons that can cause Paul kill Jim on purpose. As we understood from what is told, Paul is fall in love with Julie although she just feels pity on him : "The poor boy was crazy about Julie and she always treated him mighty nice and made him feel like he was welcome, though of course it wasn’t nothing but pity on her side" But according to Paul, Jim never treated her right. He faked her by mimicking Doc. Stair when Doc. Stair was away and made her come to doctor’s office. By the way he and some of his friends hid near the office and laugh at her when she realized the trick. They made fun of her till she got home. Later, when Paul learned this he told the whole story to Doc. Stair. He replied Paul that he would make Jim suffer some how : "It’s a chinch Doc went up in the air and swore he’d make Jim suffer" These words from Doc. Stair may well encourage such a person like Paul about punishing Jim Kendall in his own way. We do not know exactly how old Paul is but it can be assumed that he is not very old, he may be a teenager. In his ages insults are much more damaging than knifes.