Gender Representation - Boardwalk Empire Essay Example for Free

Gender Representation Boardwalk Empire Essay As a hybrid genre, the representations in Boardwalk Empire are complex, contradictory, unconventional, conventional and stereotypical, whilst challenge stereotypes. Set in the 1920’s during prohibition, Nucky is a corrupt Republican politician and gangster, who has risen to his position through bribery, corruption, and murder. The series begins as prohibition begins, with Nucky toasting the government who ban alcohol; â€Å"†¦to those beautiful ignorant bastards in Washington†. As a gangster, Nucky knows he can make millions by supplying illegal alcohol to the public and is portrayed as a businessman, making money for all the ‘respectable’ local dignitaries that sit around his table; the chief of police (his brother Ely), the mayor, the head of the port authority, local Politicians, etc. He sees an opportunity through the prohibition to increase his fortune. There is a lot of juxtapositioning in the first episode to show us the various sides of Nucky, as a violent alcohol heist is followed by Nucky addressing a Ladies’ Temperance Society. Nucky weaves a myth of his own childhood of poverty, catching rats for his family to eat, to the gasps of the audience. Embodying the American Dream, Nucky has ‘risen’ from very humble beginnings to be top man in the state, he is merely seeking the ‘women’s vote’ for his Political re-election and often shows their ignorance of world politics proves them an easy mark for manipulation to gain full power over the Atlantic City. Nucky is a complex protagonist and anti-hero who is both despicable and admirable. He is obviously very clever, charming, funny, calculating, ruthless, and a skilful businessman and gangster. He juggles a legal political life with his illegal prohibition life, dealing with a constant flurry of unexpected problems as they arise. He manipulates people in ways that should make audiences hate him but Steve Buscemi (and the writers) manages to portray him as a complex character that seeks more than just money. The low camera angles throughout help suggesting Nucky is a very powerful figure in the drama. The power wield of woman in Boardwalk Empire is largely associated with sex, and furthermore this power of woman is represented through the male characters using it against eachother. For example Gillian Darmody, mother of gangster: Jimmy Darmody and a topless dancer in the city, plays a pivotal role when she sleeps with a rival gangster: Luciano in order to detain him until he can be collected and dealt with. Her sexual power is turned to the gangsters own advantage. Lucy Daziger is another key representation of sexual power and woman in Boardwalk Empire. She is the beautiful mol and mistress of Nucky who is often a negative representation of woman – dismissed constantly in favour of Nucky’s political and illegal life. She is objectified by him and others and is kept at his beck and call. During an evening at dinner with others, Lucy insists she has a brain but is quietened by Nucky, and we see Lucy has no place for opinion at the dinner with the Commodore in terms of politics. When Nucky rejects Lucy, he favours Margaret, because she is intelligent and sees her more as an equal for example at the same dinner Margaret expresses deep knowledge and understanding of politics. Lucy is extremely jealous of Margaret as Nucky clearly shows more affection for her, which is unconventional as Lucy is the beautiful mistress, often seeming powerful, Margaret is the opposite.. Margaret is the other key representation in the drama as she challenges the notion of ‘the little woman’ throughout the series. An Irish immigrant, clever, brave, and moral (but racked by guilt), her motives are often those of a protective Mother. Initially established as naive and unsophisticated, particularly by her dowdy dress codes i. colour codes are very dull: browns, greens, her deferential body-language, and her thick Irish accent, she is represented as a weak, ordinary and poor woman. For example her dress codes of poor clothing often lacking in quality, and colour. Margaret grows in confidence throughout the seasons, as her and Nucky begin a relationship. An Irish immigrant she is wise beyond her years, Margaret quickly becomes versed in the dealings of her â€Å"husba nd† and becomes a supportive and protective ‘wife’ for his chaotic life. In her previous marriage Margaret was represented in a weak and negative way enduring endless beatings from her husband Hans. An incident of abuse had caused Margaret to miscarry her 4th child, and so Nucky ordered to have Hans murdered. Margaret knows of this but chooses to remain silent for the benefit of herself and her kids, later racked with Catholic guilt over the murder, their life, and their source of income. Nucky proceeds to live with her and her children, becoming a sensitive father figure to the kids, and a loving ‘husband’ to her.

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

Natural Family Planning :: essays research papers fc

The Natural Failure of Planning   Ã‚  Ã‚  Ã‚  Ã‚  Are modern forms of contraception naturally and morally wrong? Pope Paul VI and his Humanae Vitae declare that technological methods of birth control are immoral and should not be practiced by Catholics. However, as our modern society illustrates everyday, this opinion is inappropriate for not only the faithful of the Roman Catholic Church, but also for non-Catholics. According to Munich Archbishop Cardinal Julius Doepfner, â€Å"Contraception is not intrinsically evil† (The Politics of Sex and Religion). There is a fine line the Catholic church draws between â€Å"natural† methods of family planning and the â€Å"immoral† methods of modern technology. After close review of Catholic doctrines, it is clear that this line does not exist. The intentions behind the actions are what matters. Therefore the encyclical of Paul VI , while maintaining good intentions, cannot give Catholics and non-Catholics alike complete guidance in complete humanness when it comes to contraception.   Ã‚  Ã‚  Ã‚  Ã‚  The major problem for the married believers in the Catholic faith is that Human Vitae neglects their ability to make moral decisions. Paul VI claims that contraception limits a person’s human totality and integrity. However, the reality is that the Church is limiting this principle of human existence by assuming the common man is incapable of making the correct moral choice. For example Paul VI states , â€Å"†¦how wide and easy a road would thus be opened up towards conjugal infidelity and the general lowering of morality.† (Human Vitae 8). It is absurd to believe that all moral problems in our society can be attributed to the introduction of birth control methods. Man, in his complete integrity and totality, is capable of judging moral from immoral regardless of the technological devices he is surrounded by. If all parts of a human are in harmony, means of contraception cannot invade this person’s complete humanness.   Ã‚  Ã‚  Ã‚  Ã‚  Scientific research shows that almost all practicing Catholics today believe that modern means of contraception does not interfere with their beliefs and morals. According to one study, â€Å"Even among married Catholic women who attend church every week, less than 4% use church-approved family planning methods-about the same as the total population.† (Catholics for Contraception). This illustrates the fact that people of faith have made their own interpretations of God’s desires and find no difference between natural family planning and modern methods of contraception. Weekly patrons of the church know the moral teachings of the Church and the consequences, yet the facts show that all believers have not come to a consensus.

Kants Moral Principles Essay -- Kant Immanuel Philosophy Morals Essay

Kant's Moral Principles   Ã‚  Ã‚  Ã‚  Ã‚  In the Foundation of the Metaphysics of Morals, the author, Immanuel Kant, tries to form a base by rejecting all ethical theories that are connected to consequences, and then focusing on our ethical motivations and actions. Kant wants to derive good characters out of contingently right actions. He believes that everything is contingent (everything can have good or bad worth, depending on how it is used). So he is trying to find the supreme principal of morality in all his reasoning. Kant also believes that an action is right or wrong based solely on the reason by which it was performed. However, a Utilitarian, like John Mill, would reject Kant’s reasoning of originating good characters out of actions alone, and instead argue that if an action has bad consequences, then the action was morally wrong.   Ã‚  Ã‚  Ã‚  Ã‚  Kant believes that an action has moral worth only if it is done out of respect for our moral code. He names this moral action a ‘duty.’ Kant also believes that in determining the moral worth of an action, we need to look at the maxim by which it was performed. So, we need to look at one’s reason for doing an action to determine if it is a duty. If the reason for performing the action is justified, then the action is a duty. However, Kant says there are two different types of reasons for performing an action. Kant calls these reasons ‘imperatives.’ The first reason for performing an action, the hypothetical imperative, is based on consequences and on our personal preferences. They are also contingent, meaning that they can be good or bad depending on how they are used. People choose to perform a given action because of the hypothetical imperative. The second reason for performing an action according to Kant is called the categorical imperative. These are not based on our preferences, don’t deal with consequences of an action, and are derived a priori. They are completely separate from hypothetical imperatives. We all have knowledge of categorical imperatives before experiencing them first. They are kind of a second nature for us, which needs to be recognized according to Kant. These are the most important reason for performing an action. These imperatives also have the characteristics that Kant needs in order to make his point that all of our moral principals are categ orical, have absolute authority, and are independent o... ...t hope to predict the outcome of any given situation. It is impossible; there is no such thing as seeing the future. So by making a false promise to your friend, you have still done the morally wrong action, even though it will most likely save them some suffering. It did indeed take away their choices, so they can’t act in a way they want to act (going to class). I happen to agree with Kant’s idea here. I think that no matter what the consequences are, performing the right action is always the right thing to do.   Ã‚  Ã‚  Ã‚  Ã‚  Overall I think that Kant has better arguments because they are directed at the individual, not at society in whole. I also agree that the moral worth of actions is determined by the motivating principal of the action, not by the consequences, like John Mill. So I am a deontologist, for the most part. However, I also agree with some of the things that Mill has to say. So is there a way that we can combine the ideas of Mill and Kant together in order to form a perfect society in which everybody is happy? I don’t know the answer to this question, but we should all strive to do so, and we should start by respecting each other’s autonomy and treating others as ends.

Adam Sandlers Kids Choice Award :: essays research papers

Adam Sandler is in control -- really The clout of a child-man Monday, April 14, 2003 Posted: 1:07 PM EDT (1707 GMT) Adam Sandler accepts a Kids' Choice Award for best movie actor. Many adult movie critics would disagree. -------------------------------------------------------------------------------- Story Tools -------------------------------------------------------------------------------- RELATED †¢ Review: Jack's back in 'Anger Management' †¢ 'Anger' tops box office with $44.5M LOS ANGELES, California (AP) -- Adam Sandler, who's become one of Hollywood's top box-office draws by playing infantile men prone to fisticuffs and tantrums, displays in real life a shambling politeness and faux-naive modesty. With a shy smile, he often looks down as he speaks, while deflecting questions with self-deprecating jokes. The 36-year-old comic's almost childlike behavior conceals his status as a Hollywood workaholic who's unwaveringly loyal to his friends. "I was in his office 12 hours a day, and he was either working with me, or working on editing something else, or working on one of his other projects," said David Dorfman, screenwriter of "Anger Management," which co-stars Sandler and Jack Nicholson. "He worked nonstop." Sandler has used his clout not only to gain greater control over his own films, but also to boost the careers of former "Saturday Night Live" friends such as Rob Schneider, David Spade and Dana Carvey by guiding their pet projects through the studio system. Dorfman described Sandler as "a benevolent mogul," and Carvey said his 2002 film, "The Master of Disguise," would have gone nowhere without Sandler's help. "I mean, I owe him. I don't really know why he did it, you'd have to ask him. But it was great to have him push it through. I guess I was nice to him on 'Saturday Night Live,' " Carvey said, adding with a laugh: "Thank God." Critical roasting But some Sandler favors backfire. He gave directing duties of "The Master of Disguise" to his longtime production designer Perry Andelin Blake, although Blake had no previous experience. Critics complained that the film was a mess, and Sony was still reworking the movie shortly before its release last summer. Carvey had already starred on the late-night comedy show for five years when Sandler began appearing in 1991, the same year as Spade, whose 2001 film, "Joe Dirt," and upcoming "Dickie Roberts: Former Child Star" were produced by Sandler. Sandler co-stars with Jack Nicholson in "Anger Management." During his five-year run on the show, Sandler was known for impish characters such as Canteen Boy and musical bits such as Operaman.

Health Care Utilization Paper Essay

The health reform debate is in full swing. Millions more people will gain health insurance, coverage will be more affordable, and people will have access to the health services they need. Health Care Reform and Access The reason for Health Care reform is to make it easier on the citizens to be able to afford health insurance in the case they were to get sick or prevent them from getting sick. The law makes it more affordable instead of the rising cost, it is lowered so people can have insurance. The Health Care Reform act made it to be were the insurance companies will be held accountable on how much they raise their rates and how their money is spent. Plus, the new law will help lower costs through new tax credits and new marketplaces where insurers will have to compete for your business. At one time insurance companies were taking advantage of the people but now they have to make sure that everything is affordable. It was amazing how they could deny children that needed medical attention because they had prior health problems. Children that were born with asthma or born with other defects were being denied health coverage. Insurance companies were putting an amount on the coverage that would giv e the patient and if that failed they would find any little mistake in the paperwork to drop their health care coverage. The Affordable Care Act creates a new Patient’s Bill of Rights that protects you from these and other abusive practices. Thanks to the Affordable Care Act’s 80/20 rule, if insurance companies don’t spend at least 80 percent of your premium dollar on medical care and quality improvements rather than advertising, overhead and bonuses for executives, they will have to provide you a rebate. Things are much better now that the insurance companies have to cover many preventive services without it being any deductibles or copays required unlike before when you had to have certain screenings and were charged deductibles and co pays. Before many Americans with pre-existing conditions were locked or priced out of the  health insurance market due to their pre-existing conditions which is not fair because many people have pre-existing conditions. Alread y, 54 million Americans with private health coverage have gotten better preventive services coverage as a result. It is good that they have made insurance companies accountable against discriminating against people with pre-existing conditions. In 2014, insurance discriminating against anyone with a pre-existing condition will be illegal. Access and Utilization Several factors such as proximity to health care providers, perceived quality of care, fees charged and perceived severity of illness have been shown to affect access and utilization of health services. The wellness models is focusing on the health of a person’s mind, body and spirit. If more people took time to prevent themselves from diseases this would slow the growth of health care expenditures. What people who fell to realize is that it is cheaper to go to a class and or treatment group, instead of having to use insurance to provide medications, procedures and treatments. Getting involve with a wellness consultant can also help with obesity. According to The U.S. Health System,† The increase in obesity in adults as well as children also increases the risk of chronic diseases such as diabetes and heart failure† (Barsukiewicz,Raffel &Raffel, 2010, p.12). If people start now with their children by teaching them healthy ways of eating there will be a decrease in t he risk of chronic disease. The choice is in the parents hands because a child eats what a parent gives. Also as a person 65 and older gets up there in age there are more chronic diseases that they are at risk of getting and more prone to get them again or worse, which than leads to more health resources such as hospitalizations or put into a nursing facility. No, we cannot from aging but we can take care of ourselves now to avoid the risk of chronic diseases. Focusing on a wellness model can reduce healthcare costs because if a patient is given the proper information needed to recognize the signs of certain diseases and the proper information to prevent certain diseases, the patient will not always have to go to their doctor every time they sense something is wrong. Another way to reduce healthcare costs would be to educate people on how to live a healthier lifestyle. Adapting a healthier lifestyle reduces healthcare costs because if an individual is eating right and exercising dai ly; they can ultimately reduce their chances  of become obese. Living a healthier lifestyle also reduces the cost of treatments and medications of some of the diseases that are associated with obesity, such as heart disease or diabetes. Universal Care: Compare and Contrast Universal health care is the belief that all citizens should have access to affordable, high-quality medical care. Universal health care is a broad concept that can be structured and funded in various ways. The common factor for all universal health care programs is that they require some form of government involvement, whether it is through legislation, mandates, or regulation. One of the key functions in a managed care is gate keeping (The Payment Process, Insurance and Third-Party Payers: A Austin PhD. Welte R.N. 20-12) which basically is a way of controlling how much health care a person can receive over a period of time. Unfortunately this means that some patients who require intense treatments mat have to get authorization prior to getting the treatment which may cause a delay in treatment that can lead to more issues for the patient. The advantages of managed cares are only for the company. Managed care plans allow doctors to be paid for each member enrolled each month which m eans that regardless of how many patients he treats he will only receive a certain amount of money this limits the access a patient to specialist or rehabilitation services. Since the doctor is only getting paid a certain amount he must see a certain amount of patients which cuts down the amount of time spent with each patient. This is the where disadvantage of Managed care comes in. The patient cannot receive the proper care because his/her HMO only pays a set amount. References Comparisons. (2013). Universal Health Care. Retrieved from http://www.stanford.edu Healthcare.gov. (2013). Affordable Care Act. Retrieved from http://www.healthcare.gov The White House. (2013). Get the Facts Straight on Health Reform. Retrieved from http://www.whitehouse.gov

Orthodontics Essay

I am currently a 4th year dental student and I would like to apply for a postgraduate residency in Orthodontics. I have assessed the advantages and disadvantages of pursuing this career and I feel that being of service to a lot of people and raising their self-esteem by beautifying them is what drives me towards this direction. I have always focused on both the physical as well as the mental enhancement of my capabilities. I have learned to focus on achievement not only as flat numbers on a page, but as an indicator that I am getting better, making progress toward being the best I can be. I believe I can be of help to the community where I belong in both the short term and long term. I know that I do not have the luxury of mediocrity or pessimism or apathy—that peak performance is demanded in this profession, We have all been in situations where the best of ourselves emerged at levels we previously thought impossible, and have seen such moments in our families, in projects that worked. I had been in projects and cultural and social activities in school that I feel would help me contribute in my efforts in pursuing Orthodontics. I believe in team productivity that would help serve self-development and personal fulfillment, and by extension, the vitality and prosperity of the school where I plan to pursue further studies. I know I can contribute to the school in my own small way because I feel most alive when engaged full-throttle. Call it positive addiction, a contributory obsession, a passion to create one’s self through one’s work, yet I thrive in that and I can’t wait to channel my energies towards these worthy efforts. I have made further explorations of what this university stands for and what it has to offer, and I have to say that my appreciation of this university has grown. I have learned that it stands not only for academic excellence that prepares students for the challenges of career and real life, but also for a value-ladened education that emphasizes values education and a concern and commitment for a more humane and just world. This university aroused my interest in particular, because it fits in with my earlier notions that education should include immersion in real life problems and challenges. I am excited and eager to find out how I can fulfill my potential by subjecting myself to the discipline and immersing myself in the daily life of this University and the many issues tied to being an educated and compassionate person in a complex world. After much reflection, I have come to regard this University as one of the best options for a young person like me. I am excited at the prospect of being considered for admission here. I hereby present myself with a strong grasp of fundamentals in dentistry, an insatiable thirst for knowledge and an array of teaching, leadership and team member skills. I sincerely hope that my background and undergraduate qualifications are deemed appropriate for higher studies in your university. I feel my best work is still in the future. I believe I can contribute and make a difference, and successfully complete the requirements, if given a chance. I am full of enthusiasm and am eager to bring to bear my personal strengths and interests, and my zeal to excel in my chosen field to the pursuit of excellence in my areas of interest.