Triggered by the “Kolombusus-21’s exhibition” Essay Example for Free

Triggered by the â€Å"Kolombusus-21’s exhibition† Essay The issue of space travel has been widely debated in recent times, with opinions ranging from total support to a waste of money. In his opinion piece in ‘Daily newspaper’, entitled ‘Exploring our dreams’, Yvette Yergon uses a humble tone in contending that the government should provide more funds available for space travel. In contrast, Dr Peter Laikis’s sarcastic letter to the editor, ‘Off the planet’ appeals to all the people who have an interest in current world dilemmas, suggesting that our governments focus and  attention should be spent here on Earth rather than space travel. Yvette opens with statistics. The claim space is only ‘160km away’, ‘while Canberra to victoria is further away’ appeals to the readers logical side. Allowing them to believe, ‘space isn’t that far away’. It allows the reader to put in perspective how far space is really away. In addition by using a distance like ‘Victoria to Canberra’ it appears to be a very achievable distance, therefore making Yvette’s ‘dream’ a very possible ‘dream’ with which the reader can identify. The statistics give  Yvette credibility. Credibility, which is extended by the inclusion of personal background information. This allows Yvette’s views accepted as believable. Referring to the new possibilities that space exploration could lead to or fortunes that lie above, like ‘10,00 tones of gold’ inclines the reader share his ‘dream’. Leaning the reader to believe that space may hold the key or play a part in the future of earth. Yvette invokes hope by inviting the reader into a story. He records the observations of a young guide who starts, ‘it might only be a dream now’ using a  personal tone pulls the reader to his side. Going on to say ‘but one day it might come true’ showing the reader that his dream might be out of reach at the moment, but in the future may be very possible. The guides youth and enthusiasm is apparent and the reader is encouraged. The visuals assist with Yvette’s arguments. The first visual is an image of Kolombus’s ship. This picture represents how that ship was once the equivalent of a spacecraft discovering new continents, when it was thought to be impossible. Byincluding this it highlights, fin ding new continents was once impossible, showing the reading that there may possible be other world that just haven’t been discovered yet. The second visual shows all the befits that come from space travel. These include solar cells, global positioning system, safe food processing, radial tyres and medical imaging. All items that are very prevalent in society today, that we would not have without space travel. This positions the reader to believe that not only will space travel help us with mapping the solar system, but it will also help us to  discover or create new resources that would be beneficial for today’s society. Yvette ends by appealing to the readers’ emotions. Yvette tells how ‘we must recharge our scientific batteries’, ‘invest in the technology of tomorrow’. By using these example pushes the readers to look past their daily lives and in to the future. Pushing the readers to believe that we can grow as a society, through the funding space travel ‘Wake-up, Yvette’ by Dr Laikis, opens with a pun on Yvette’s title , suggesting that he must literally wake up from his dream, as it will only be a dream.  By using this humorous tone, draws his reader to believe that Yvette’s ‘dream’ absorbed and childish. He follows with ‘when did governments ever fund†¦ for peaceful purposes’, showing that his idea is also absurd. Dr Laikis points to a major flaw in Yvette’s argument. Even if countries wanted to explore space, it is very unlikely for every country to agree on the politics. This criticism, allows the reader to see how unlikely Yvette’s ‘dream’ may be. Dr Laikis finishes with an alternant ‘dream’; his dream is much closer to home. By doing this he reveals to the reader that we don’t need to look out in space to grow, but fix the problems on earth. Both Yvette and Dr Laikis were both persuasive, as they each positioned the reader to assume both were correct. Yvette persuaded by using a neutral tone, with many stories of what ‘could be’ if the government decided to fund the government. While Dr Laikis persuaded by using a sarcastic tone and mocking Yvette’s points while still pointing out their flaws. Yvette’s opinion piece was overall more persuasive as it had statistics and facts, while Dr Laikis was only his opinion.

Case Study: Hypertension in Pregnancy

Case Study: Hypertension in Pregnancy Main Complaint My patient Madam Siti a 31 year old Indonesian maid Gravida 3 para 2 at 38 weeks and 1day of Period of Amenorrhoea (POA) was admitted to the ward for blood pressure stabilization and induction of labour (IOL). History of Presenting Illness She was referred from antenatal clinic during follow up in PPUKM on 29/11/2010. During the check up at the follow up, her vital sign showed she was afebrile, pulse rate of 90beats per minute and blood pressure was noted to be 160/100mmHg and no abnormality was found in the urine. During booking her blood pressure was noted to be 100/70mmHg and she was normotensive throughout the pregnancy up until at 38weeks and 1day of POA. She complained to have frontal headache and nausea 2 days prior to admission. She denied symptoms of impending eclampsia such as blurring of vision, epigastric pain and vomiting. There was also no dizziness, shortness of breath, chest pain, reduced urine frequency and leg swelling. She also had per vaginal discharge which was whitish and creamy in nature, no foul smelling and no pruritus vulvae. There was no urinary tract infection symptoms such as urgency and dysuria. Fetal movement was good. She was admitted to the ward for further management. Antenatal History This is an unplanned but wanted pregnancy. Her urine pregnancy test (UPT) was positive at 6weeks of POA. Dating scan done at 15weeks of POA which correspond to date. Booking was done at 15weeks of POA at private clinic at Medviron. Antenatal screening done showed that: Blood Pressure : 110/70mmHg Haemoglobin level : 12.8g/dL Height : 158cm Weight : Pre : 62kg Current : 69kg Blood Group : O Positive VDRL/HIV/HEP B : Non Reactive Urine Albumin/Sugar : Nil No MGTT was done. Despite having a family history of diabetes mellitus. Latest scan done at 38 weeks and 1day POA and all parameters are correspond to date. It was a singleton fetus on longitudinal lie and cephalic presentation. Fetal heart and fetal movement are seen. Amniotic Fluid Index are 11. Estimated fetal weight was 3.3kg and placenta was on anterior upper segment. Otherwise, antenatal visits are uneventful. Past Obstetric History On 1999, she had a full term normal pregnancy and delivered a baby girl by Spontaneous Vaginal Delivery (SVD) at a hospital in Indonesia and weight of the baby was 2.6kg and is alive and well. On 2007, she also had a full term normal pregnancy and delivered a baby boy by spontaneous vaginal delivery also at Indonesia. The baby weight 2.3kg and currently is alive and well. Both of her children stays with her mother at Indonesia. Past Gynaecology History She attained her menarche at the age of 13year old with 28 to 30days regular cycle with 7days of menses. She denied dysmenorrhoea, menorrhagia, intermenstrual bleeding, dyspareunia and postcoital bleeding. As for contraception, she uses Implanon for 4years from 2002 to 2006 between the first and the second pregnancy. She was then on Oral Contraceptive Pills for 2months and had stop taking them afterward until today. After this pregnancy, she is keen to take Intrauterine Contraceptive Device (IUCD). She had never had pap smear done before. Past Medical History Nil. Past Surgical History Nil. Allergy and Drug History No known drug allergy or food allergy. Family History Her mother is alive and was diagnosed to have diabetes mellitus and hypertension and currently on medication. Her father died on 2007 due to renal failure. She had 3siblings and currently all of them are alive and well. Social History She has been married for 12years and came to Malaysia on 2006 which was 4years ago. She lives in a terrace house at Cheras and worked as a maid. Her husband came to Malaysia 5years ago but had recently go back to Indonesia 2months ago. He previously worked as a contractor for the same employer. He planned to return to Malaysia after his permit is renewed. Both of them does not smoke or consumed alcohol. Both of their children were in Indonesia and are taken care by her mother. Relevant Clinical Examination General On examination, she was alert, conscious and she was not pale or jaundiced. Her Blood Pressure was 142/92mmHg lying and 152/104mmHg standing. Her pulse rate was 90beats per minute and respiratory rate was 20breath per minute. She was afebrile. Her current weight was 69kg. There was no pedal oedema noted. Thyroid Gland There was no scar, lump or dilated veins noted around the area of the neck. There was no lymphadenopathy noted. Breast On inspection, both breast were symmetrical and bilaterally in size. Both her nipple were not hyperpigmented or retracted. There was no nipple discharge. Her breast were non tender and no mass was palpable. Cardiovascular System On inspection of the hand, there was no clubbing and peripheral cyanosis. Inspection of the mouth showed that there was no central cyanosis and hydration status was good. There was no surgical scar and no notable abnormalities detected on the praecordium. Jugular Venous Pressure was not raised. Peripheral pulses were present with normal rhythm and good volume. There was no radio-radial delay or radio femoral delay. There was no collapsing pulse. On palpation, apex beat was not displaced it was palpable at the 5th intercostals space and left midclavicular line. There was no parasternal heave and thrills detected. On auscultation, the first and second heart sounds were heard with no murmur or added sound heard. Respiratory System On inspection, the chest moved bilateral symmetrically with inspiration. There was no scars and deformities noted. She did not use accessory muscles on breathing. On palpation, her trachea was not deviated. Chest expansion was equal bilaterally. Air entry was good and equal bilaterally as evidenced by normal vocal fremitus and vocal resonance. Percussion of both lungs were resonant. There were vesical breath sounds equal on both sides with no added sounds on auscultation. Neurological System She was orientated to time, place, and person. All cranial nerves were intact. Both her upper and lower limbs were normal. Muscle tones, power, and reflexes were all good and normal. Abdominal Examination On inspection, the abdomen was distended by gravid uterus as evidenced by cutaneous signs of pregnancy such as linea nigra and striae gravidarum. The umbilicus is centrally located and flat. No scars noted and no dilated veins seen. On palpation, her abdomen was soft and non tender and uterus was not irritable. Clinical fundal height revealed that the uterus was 38weeks in size and was correspond to date. Symphysiofundal height was 37cm. Palpation of the fetus showed that it was a singleton in longitudinal lie with cephalic presentation. The head was 3/5 palpable and not engaged. The fetal back was on the maternal left side. The liquor was adequate and estimated fetal weight was 3.2 to 3.4kg. Pelvic Examination Vaginal examination was not done. Per Rectal Examination Per rectal examination was not done. Summary of Case 31year old maid gravida3 para2 at 38weeks and 1day POA admitted for blood pressure stabilization and induction of labour (IOL) due to gestational hypertention. Diagnosis and Differential Diagnosis Provisional Diagnosis Gestational Hypertension: She develop hypertension which is a blood pressure of 140/90mmHg aand above recorded on 2 separate occasions at least 4hours apart. Hypertension occur in second half of pregnancy which is after 20weeks of gestation. She is previously normotensive. There is absence of proteinuria She had risk factor; family history of hypertension. Differential Diagnosis Pre-eclampsia: Points for: Hypertension at least 140/90mmHg recorded on 2 separate occasions at least 4hours apart. Hypertension occur at second half of pregnancy, after 20weeks gestation. She is previously normotensive. She had risk factor; family history of hypertension. Points against: There was absence of proteinuria of at least 300mg Protein in a 24hour collection of urine. She had no risk factor such as pre-existing hypertension or pre-eclampsia. Chronic Hypertension: Points for: She has a family history of hypertension. Points against: She is normotensive prior to pregnancy. She had no other disease such as renal or connective tissue disorders that can lead to hypertension. Relevant Investigations with Reasons Full Blood Count To check whether patient is anaemic or not (Hb). To confirm patient is not on any infection such as urinary tract infection (WBC). White Cell Count + 14.2 x 109/L Red Cell Count 4.18 x 1012/L Haemoglobin 12.3 g/dL MCV 37.1% MCH 88.7 Fl MCHC 29.3 Pg RDW 33.0 g/dL Mean Platelet Volume 8.0 Fl Platelet 302 x 109 /L Neutrophils ++ 10.3 x 109 /L Eosinophils 0.4 x 109 /L Basophils 0.0 x 109 /L Lymphocytes 2.6 x 109 /L Monocytes 0.9 x 109 /L Nucleated RBC 0 x 109 /L Comment: There is a reduction of Red Cell count. This is due to pregnancy, as there is haemodilutional effect due to an increase in plasma volume. Patient is not anaemic as haemoglobin is on the normal range. However, there is leukocytosis mainly the neutrophils. This suggest an infection most likely bacterial in origin such as urinary tract infection. Renal profle To exclude secondary cause of hypertension due to renal damage. To detect abnormality in the level of serum urea and creatinine that will indicate renal damage or failure. Sodium 139 mmol/L Potassium 4.0 mmol/L Urea 2.3 mmol/L Creatinine 54 umol/L Comment: There is hypouremia. This is normal in pregnancy, as there will be an increase in Glomerular Filtration Rate (GFR), therefore there will an increase in clearence of urea in the body. Besides that, a reduction in deamination process in the maternal body will also cause blood urea to be reduce. Liver Function Test To see whether patient had any liver damage Albumin 33 g/L Total Protein 68g/L Bilirubin toral 6 umol/L ALT 19 u/L ALP + 141 u/L Comment: There is hypoalbuminaemia. There is increase level of Alkaline Phosphatase (ALP) due to placenta production. Thus, making it a normal physiological reaction. Serum Uric Acid Serum uric acid is a sensitive indicator of renal damage in pre-eclampsia. Uric Acid 371 umol/L Comment: Serum uric acid level is normal. Suggesting there is no renal damage. PE/ Pre-eclampsia Chart To monitor her blood pressure on lying and standing To monitor her urine whether there is albuminuria or not. To detect pre-eclampsia. Result: Other than the increase in blood pressure prior to delivery, there is no albuminuria noted. Therefore, patient did not have pre-eclampsia. Fetal Kick Chart To monitor the fetal well being. If there is decreased fetal activity, it may indicate some degree of fetal compromise. Cardiotocography (CTG) To monitor the heart rate and contraction of the uterus to detect abnormalities in the pregnancy. Ultrasound. To assess the fetal growth. Identify The Problem in Terms of Priority Gestational Hypertension. Induction of labour in gestational hypertension. Immediate and Subsequent Management Admit to ward for BP monitoring and stabilization. Monitor for any signs and symptoms of impending eclampsia. Bed rest. BP monitoring 2hourly for 24hours. If blood pressure reduce or return to normal patient can be discharge and to come again for antenatal follow up. Bed rest continued if persistent. Antihypertensive medication given if BP consistently noted to be 150/100mmHg. Preferred agent are alpha and beta blockers agent such as labetolol or methyldopa. Pre-eclampsia chart to exclude pre-eclampsia. CTG and fetal kick chart monitoring. Gestational hypertension not resolve, induction of labour is recommended. If induction of labour fails or spontaneous delivery is not possible, prepare for lower segment caesarean section (LSCS). Final Conclusion/ Plan for Further Management/ Patient Progress On admission on 29 November 2010, her blood pressure (BP) was high which was 142/92mmHg lying and 152/104mmHg standing. She was then given 200mg labetolol TDS. Pre-eclampsia chart done to monitor albumin in the urine. She is also monitored on signs and symptoms of impending eclampsia. Her BP was monitored half hourly for 2hour and induction of labour (IOL) is done soon after BP is stabilize. On the next day , 7.15am, Bishops Score was done and result was 2/13. Therefore cervix was not favourable. First 3mg of Prostin tablet was inserted into the posterior fornix. CTG was then done after 1hour to monitor for uterine hyperstimulation of fetal distress. The abdomen and cervix will be reassess in 6hours time. Tablet labetolol was continued and signs and symptoms of impending eclampsia (IE) was monitored. Six hour later, patient had contraction (irregular) but no leaking liquor noted. There was no signs and symptoms of IE, per vaginal discharge and fetal movement was good. Her BP was 129/92mmHg which had decreased slightly. On palpation, her abdomen was soft and non tender. Uterus was 38weeks, presenting part was 3/5 palpable. Bishops Score was done again and cervix is still unfavourable at 3/13. Second prostin was inserted at the posterior fornix. CTG was done 1hour post prostin for monitoring. Six hour later, she had 2 contraction in 10 minutes and it was moderate. There was no leaking, no per vaginal bleeding and the fetal movement was good. Her BP on lying was 112/86mmHg and 122/90mmHg on standing, well controlled BP. Vaginal examination revealed normal vulvovaginal, cervix dilated to 1cm, os was 3cm membrane intact and station was -2. 2hour later, the contraction was 3 in 10minutes and no leaking liquor. Vaginal examination showed 1cm cervix, 4cm os. Artificial Rupture of Membrane (ARM) was done. Clear liquor was noted. Patient was in active phase of labour and was sent to the labour room for delivery. Entonox was given for pain management in the labour room. Contraction was 3 in 10 minutes with moderate intensity and os was 4cm. one and a half hour later, patient complained of having strong contraction and felt the urge to bear down. Vaginal examination done and os was fully dilated at 10cm. She delivered a baby boy weighing 2.53kg with apgar score of 8 in 1minute and 9 in 5minutes. The patient developed first degree tear, placenta was complete weighing 590gm. Estimated blood loss is 250cc. Cord pH was 7.312. In the ward, day 1 post SVD she was alert, conscious, comfortable and was not pale. Her BP was 118/83mmHg which was normal and her pulse rate was 96beats per minute. She was afebrile. Abdominal examination showed that her abdomen soft and non tender. The uterus was well contracted at 18weeks in size. The lochia was normal. Breastfeeding was established and she was ambulating well. The patient can tolerate orally and had pass urine and bowel movement. She had completed her family size and plans to use intrauterine contraceptive device (IUCD) for contraception. Prescription of labetolol was stopped as her BP has been stable and she had delivered her baby. She was then allowed for discharge and to come again 2weeks later to review her BP. She was given hematinics to increase haemoglobin level. Discharge Summary Name : Siti Arifah Age : 31 MRN : N285492 Race : Indonesian Gender : Female Discharge Date: 01/12/2010 Case Summary Date of admission : 29/11/2010 Date of delivery : 30/11.2010 at 22:35 Date of Discharge ; 01/12/2010 31year old, para 3 @38weeks and 4days of POA, post spontaneous vaginal delivery (SVD) with first degree tear diagnosed with gestational hypertension @ 38weeks. Antenatally, Dated at 15weeks. Antenatal clinic uneventful. Booking blood pressure (BP) 100/70mmHg. Has been normotensive throughout pregnancy (BP range 110-120/70-80mmHg) until on 38weeks, noted that BP at clinic 160/100mmHg. Tablet labetolol 200mg given stat at the clinic. Admitted to ward for BP stabilization and started on tablet labetolol 200mg TDS. Medical/surgical History Nil. VDRL/HIV/Hep B Non reactive. Admitted in for BP stabilization. Before admit and in the ward, patient complaint of headache. On day 2 of admission, cardiotocograph (CTG) showed sleeping pattern. Opted for induction of labour (IOL). Prostin inserted 2 times. After 7hours of second prostin insertion, patient went into active phase of labour, os 4cm. Artificial Rupture of Membrane (ARM) was done with clear liquor. Os fully after 1 hour 30minutes without augmentation. Second stage 10 minutes. Third stage 13minutes. She successfully delivered a baby boy of: Weight : 2.73kg pH : 7.312 TSH : pending G6PD : normal Estimated Blood Loss (EBL) : 250cc Currently she is normotensive. There is no acute complaints. No signs and symptoms to suggest of anaemia. She is tolerating orally and ambulating well. Passing urine/bowel open without problems and there is no excessive bleeding. Her baby is well and active, suckling well. BCG/Hepatitis 1st dose has been given. On examination, Her vital signs are stable. She is pink and alert. Abdomen soft and non tender. Uterus well contracted and 18weeks in size. There is no excessive bleeding. Lochia is normal. Mother Haemoglobin: 12.3g/dL Contraception: Intrauterine contraceptive device (IUCD) Plan; Off labetolol EOD BP at local clinic To come again (TCA) in 2weeks to review BP. Continue Haematinics. Medications Tablet Hematinics OD Tablet Gelusil Ponstan TDS Syrup lactulose 15mls TDS Diagnosis: Post- SVD with first degree tear. Prepared by, Connie (CONNIE KABINCONG) House Officer Obstetric and Gynaecology ward UKMMC Referral to Doctor For Continued Management To: Medical officer of Obstetric and Gynaecology Department Date: 01 December 2010 Dear Doctor, Regarding: Siti Arifah, N285492 Thank you for seeing this patient, Siti Arifah, a 31year old Indonesian maid, para 3 post spontaneous vaginal delivery (SVD) with first degree tear at 38weeks and 2days of period of amenorrhoea (POA). She was admitted for blood pressure stabilization and induction of labour. She was referred from antenatal clinic when it was noted that her blood pressure was high which was 160/100mmHg. She never had history of hypertension before until on 38weeks and 1day of POA. However, she had a family history of hypertension. She was given labetolol for blood pressure stabilization and was given tablet Prostin 2times to induce the labour. She was then delivered a baby boy by SVD and her baby was alive and well. Her blood pressure was 118/83mmHg after the delivery. She was then stopped on taking Labetolol. Kindly see this patient for blood pressure monitoring and to exclude pre-existing hypertension in this patient. Thank you. Regards, Connie (CONNIE KABINCONG) House Officer Obstetric and Gynaecology Ward UKMMC Mock Prescription: For Patient on Discharge Name : Siti Arifah Age : 31 MRN : N285492 Race : Indonesian Gender : Female Discharge Date: 01/12/2010 Tablet Haematinics OD Tablet Gelusil/Ponstan TDS Syrup Lactulose 15mls TDS By, Connie (CONNIE KABINCONG) House Officer Obstetric and Gynaecology Ward UKMMC Professionalism Component Communication Issues As communication will be crucial in our future career as a doctor, a good basic has to be established now. As a good communicator we must be able to convey our message and information to our patient either in the form of words or from plain body language. Fortunately, my patient Madam Siti was very cooperative. I was able to establish rapport with her rather rapidly. She became more comfortable while answering my questions. Management wise, I found that she was well assured and well informed about what was being done for her. The doctor in charged informed her about her condition and told her about the possible complication that may arise and enough reassurance was given. Psychosocially, she did admits that she was a little scared of the possible complication that might affect she and the baby. Furthermore, her husband was not able to be by her side for moral support. I spent some times consoling her and she felt better afterward. Financially speaking, she and her husband total household income is currently not sufficient as she only earn approximately RM1000 per month and her husband is currently unemployed and waiting for his permit to return to work to Malaysia. However she claimed that her employer are offering to help her out during her confinement period. Spiritual Issues She is a very religious woman and has a strong spiritual side. She believe that God will helped her through this challenge and it had made her become quite cheerful and optimist despite of her current state. Ethical Issues As medical student, we have been reminded from time to time that medical ethics are crucial in order to be good doctors in the future. A good doctor should always put the patients life at the highest priority and respect the patients right to autonomy, information and privacy. Madam Siti should be counseled on options, pros and cons of the choices and the choice that made by her with guidance and advice by the doctor. No information should be withheld from her. Ethically as patient they also entitled to their privacy and confidentiality. Unfortunately, in a teaching hospital such as HUKM, patients privacy is sometimes compromised. Madam Siti was continuously approached by the students who wished to clerk her although it is very tiring to repeat all the words again and again, she still can tolerate it. Unfortunately there isnt much things I can do to help her but I can learn from this by learning not to disturb patient during the visiting hours or when they are tired while still grabbing every opportunity to learn in the ward. Professional Judgement In managing obstetric patient, we must take into account that we are not only dealing with one life but two. Thus extra caution must be taken. Especially with Madam Siti condition, as hypertension in pregnancy if it is not well controlled and monitored it could easily turns into something terrible very quickly. I felt that the management of Madam Siti was fair, she was properly counseled on maternal and fetal complication that could arise from hypertension in pregnancy. She was also well informed on the results of all the investigation done on her and her current management. Critical Appraisal Hypertension in pregnancy is defined as Blood Pressure more than or equal to 140/90mmHg in previously normotensive women that occur in 20th week of gestation without proteinuria until 6weeks postpartum. Or alternatively, a rise in systolic BP of more than 25mmHg or diastolic BP of more than 15mmHg compared with booking BP. Hypertension in pregnancy caused an increase in maternal and perinatal morbidity and mortality. Normal BP usually never went beyond 120/80mmHg. However in pregnancy plasma volume increases on an average 1200ml. So vasodilatation is needed to maintain the peripheral pressure. If the vasodilatation action is counteract by arterial spasm, hypertension occurs and lead to reduction in perfusion to all organ. This includes the uterus and placental site. Hypertension in pregnancy can be divided to pre-eclampsia, gestational hypertension, chronic hypertention, pre-eclampsia superimposed of chronic hypertension. Pre-eclampsia is defined as hypertension of at least 140/90mmHg recorded on 2 separate occasions with the significant proteinuria of more than 300mg in 24hours urine collection after 20weeks of gestation in a previously normotensive women and resolve completely by 6weeks postpartum. Eclampsia is a serious complication and life threathening complication of pre-eclampsia. It is defined as convulsions occurs in a woman with pre-established pre-eclampsia in the absence of any neurological or metabolic cause. Chronic hypertension is caused either due to essential hypertension or secondary hypertension. Secondary causes include renal artery Stenosis, glomerulonephritis, cushing syndrome and pheochromocytoma. Chronic hypertension is a hypertension diagnosed prior to 20weeks of gestation or history of hypertension preconception and de novo hypertension in late gestation that fails to resolve postpartumly. Pre-eclampsia superimposed on chronic hypertension is diagnosed when there is: De novo proteinuria after 20week gestation Sudden increase in magnitude of hypertension Appearance of features of pre-eclampsia-eclampsia Sudden increase in proteinuria in women with preexisting proteinuria in early gestation in women with chronic hypertension. Risk factors for women to develop hypertension in pregnancy can be divided into obstetric, medicaland social aetiology. In obstetric aetiology, the risk factor can be further divided into maternal and fetal risk factor where: Maternal risk factors are: Nulliparity or primigravida Advanced maternal age or extreme age (35year old) Family history of hypertension, pregnancy induced hypertension, pre-eclampsia and eclampsia. Previous history of gestational hypertension, pre-eclampsia, eclampsia. Maternal obesity (>80kg) Fetal risk factors are: Multiple pregnancy Molar pregnancy Hydrops fetalis From medical aetiology the risk factors are: Diabetes mellitus or gestational diabetes mellitus Established hypertension Connective tissue disease Renal disease: glomerulonephritis, renal artery Stenosis Endocrine disease: cushings syndrome, pheochromocytoma. From social aetiology the risk factors are: Smoking Alcohol consumption Complication that can arise from hypertension in pregnancy are eclampsia, intrauterine growth restriction, renal failure, thrombocytopenia, abruption placenta, subcapsular haemrrhage and liver dysfunction. Treatment wise, patient need to be admitted to hospital first fo r BP monitoring and stabilization. Used of antihypertensive agents that may be used in hypertension in pregnancy is Labetolol, which is a combined alpha and beta blocker. By blocking alpha adrenoreceptor in the peripheral arteries, it reduced the peripheral resistance. At the same time beta blocking effect protects the heart from reflex sympathetic drive normally induced by peripheral vasodilatation. Nifedipine, a calcium channel blocker can be use as an alternative. Delivery is the ultimate treatment of hypertensive in pregnancy and its timing is dependent on the observation of fetal and maternal well being. Prolongation of pregnancy by drug therapy may reduce the risk of prematurity and improves the chances of delivery. Reference Lists Obstetrics By Ten Teachers, 18th edition; Philip N. Baker. Obstetrics Illustrated, 7th edition; Kevin P. Hanetty, Ian Ramsden, Robin Callander. Handbook of Labour Practice, 2nd edition; Dr. Yun-Hsuen Lim, Professor Dr Muhammad Abdul Jamil, and Professor Dr. Zaleha Abdullah Mahdy. A Practical Approach to Obstatric Problems for the Undergraduate, 4th edition; Professor Kulenthran Arumugam.

The Third And Final Continent Essay

The Third And Final Continent Essay The character I have chosen for analysis from Jhumpa Lahiri short story, The Third and Final Continent, is the narrator, a very dynamic character who adapts to the traditions and lifestyles of the continents he travels to especially America. The narrator exhibits the most characteristics than any other character in the story because he is talking about his life and the actions that he takes when encountering a certain obstacle. The narrator also shows the most change than any other character. Living from one continent to another continent and then to another continent again can dramatically change how a person lives, thinks, and even eat. Despite all the changes that he experiences he still retains some traditions from his culture of origin with the help of a stranger that he meets. This is a positive characteristic that distinguishes the narrator from any other character in the story. The narrators life contrasts somewhat to other immigrants because they must all undergo a certain t ype of change and must worry about the passing of traditions to their American born children. The life of the narrator is a clear example of what most immigrants must go through when living in a new continent. The tone of the narrator sounds somewhat non enthusiastic or plain due to the fact that both of his parents have passed away. He shows strong love and respect for his parents. Before we cremated her I had cleaned each of her fingernails with a hairpin. I had assumed the role of eldest son, and had touched the flame to her temple; to release her tormented soul to heaven (Jhumpa Lahiri 654). The narrator is also a very well educated man, a graduate from LSE (London School of Economics), and he also has a knack for learning new things. I attended lectures at LSE. I read every article and advertisement, so I would grow familiar with things, and when my eyes grew tired I slept (Lahiri 650-651). The narrator faces an internal conflict: how can he be a modern American Indian and retain some of the old traditional Indian ways at the same time? His quest continues with the birth of his son, afraid that his son will forget his Indian traditions. So we drive to Cambridge to visit him, or bring him home for a weekend, so that he can eat rice with us with his hands, and speak in Bengali, things we sometimes worry he will no longer do after we die (Lahiri 662). The narrator tells to his son the journey of himself surviving in three totally different continents as a way for his son to gain the morale that he needs to overcome any obstacle. There is evidence in the story which suggest that the narrator is trying to find solutions for his problem because he tries to retain some of his old traditional ways by eating egg curry and walking barefoot in the house and being modern by telling his wife that she does not have to wear her sari all the time. And took turns cooking pots of egg cur ry, which we ate with our hands on a table covered with newspapers (Lahiri 650). There is no need to cover you head, I said. I dont mind. It doesnt matter here (Lahiri 660). Cooking egg curry is his main way of keeping Indian tradition alive. He cooks egg curry in India, in the crowded room in London, and even in his new home in America. He can never abandon his roots and obeys every aspect of his Indian culture. I regarded the proposition with neither objection nor enthusiasm. It was a duty expected of me, as it was expected of every man (Lahiri 654). The neutral remarks that he makes towards his arrange marriage shows that he is a very religious man, keeping alive some aspect of his tradition to allow him to survive the toughest of times. The narrator is astounded when he finds out from Mrs. Crofts daughter Helen that his land lady is over a century years old. I was mortified. I had assumed Mrs. Croft was in her eighties, perhaps as old as ninety (Lahiri 657). He could not bare the fact of a widow living all alone by herself because he once had close encounters with a widow before which drove her insane, his mother. Widowhood had driven my own mother insane. What pained me the most was to see her so unguarded And so it was my job to sit by mothers feet (Lahiri 657). When he realizes that Mrs. Croft is very old and also a widow for so long he starts to take care of her as if she was his own mother. At times I came downstairs before going to sleep, to make sure she was sitting upright on the bench, or was safe I her bedroom (Lahiri 658). This shows the narrators strong bond between stranger and stranger which later strengthens his relationship with Mala. His encounters with his land lady, Mrs. Croft guided him with his new life in America. He shows admiration for Mrs. Croft because she has survived for so long while keeping all of her old traditions intact and passing them on to her children. She added that it was also improper for a lady of Helens station to reveal her age and to wear a dress so high above the ankle (Lahiri 657). This paves the way for how the narrator should live his life and teach his son about Indian traditions. Mrs. Croft also symbolizes the narrators mother saying that Maya is a perfect lady! (Lahiri 662), as though she is approving of Maya to be the narrators wife. For immigrants, the challenges of exile, the loneliness, the constant sense of alienation, the knowledge of and longing for a lost world, are more explicit and distressing than for their children. On the other hand, the problem for the children of immigrants, those with strong ties to their country of origin, is that they feel neither one thing nor the other (Lahiri 663-664). This quote from Lahiri herself is basically what the theme of The Third and Final Continent is all about. It strongly interprets the narrators character in the story as an immigrant and the emotions that he feels when he enters a new country. It also explains the inner conflict in which he is trying to overcome of being a modern Indian and a traditional Indian at the same time, while explaining to his son how important it is to keep a little bit of tradition alive within you. Although not every immigrants life in America can relate to the narrators, it is true however that they all must undergo some type of chan ge when living in a new country for the very first time. Works Citied Lahiri, Jhumpa. Chapter 20/Fiction For Further Reading. Literature Reading, Reacting, Writing. 7th ed. Boston: Wadsworth Cengage Learning, 2010. 650-64. Print.

Essay --

Everything we need is in our daily life is based on demand and supply. The country is based on the effects of both demand and supply. Whenever demand is affected it lead to shortage of various needs that are in demand and whenever supply is affected it leads to shortage of supply in the country’s economy. Moreover the things we need in our daily life is also affected on both demand and supply. Demand leads to the total quantity on goods or services that are needed to buy various commodities and supply is the quantity of goods and services business will make available to make profits. Thus in our daily life everything is based on the demand and supply from a small commodity to a large corporations. Moreover the company’s shares or bonds are also based on the effect off demand and supply. Lower the demand will be the lower price of goods and services and vice-versa. And higher the supply will lead to high price of goods and services. Demand lowers supply in a simple case price of each and every commodity will be affected by demand and supply. Whenever the demand change it will lead to change in the taste of the customer and will lead to change in the taste of fashion for customers, also lead to change in price of related goods i.e goods are not related with each other thus they are of different taste of preference is different. Change in demand will lead to change in number of buyers of economy because when demand changes or exceeds it leads to increase in number of commodity and whenever demand lowers it leads to increase in prices of goods and services. For instance – The price of canada’s farmland is rising on strong demand so that this will increase the number of buyers for various reasons and there will be effect on price of va... ...ses, still moving ahead throughout some days so this increase the demand and supply issue to much extent as both are affected through same number of days with most of the important content with demand and supply related issues. After this we can also bring up after several years of back to back record settings gains. Some investment funds which have already been scaled back on the purchases and are still moving ahead but at a more cautious pace. Both demand and supply are now most important thing that constitutes the world of and economy as most of the economy is dependent upon the demand and supply affect but prices of farmland are rising on strong demand and supply effect. So in Canada now according to other countries demand of particular goods have been increased related to others in the economy. Thus price of demand and supply is related to price in the economy.

Challenging Gender Roles in English Society Essay -- England Literatur

Challenging Gender Roles in English Society The age of Shakespeare was characterized by an overwhelming tendency for women to be looked down upon as the inferior gender. Women of the time were expected to be submissive, dutiful, obedient, and predominantly silent. The idea of an independent, out-spoken woman would have challenged all of the societal values of the time. Shakespeare, however, challenged the traditional patriarchal values of his time by introducing powerful and highly influential female characters in some of his most memorable plays. Lady Macbeth and her earlier counterpart, Volumnia, both serve pivotal roles as dominant and commanding mother figures and also challenge the traditional role of the dutiful wife. Both of these independent, strong-willed women are far ahead of the times in their approach to marital, maternal, and societal involvement. Shakespeare successfully portrays his women in a new light, very different from the perspective with which women were viewed at the time. Both women challenge traditional patriarchal values of English society and establish the female character as a significant and heroic figure among Shakespeare’s prominent male figures. Lady Macbeth, perhaps the most famous of these spirited women, is a particularly prominent character in Shakespeare’s tragic Scottish play, Macbeth. Her decisive and determined mentality serves as the driving force in Macbeth’s journey toward tragedy. It cannot be mistaken that Macbeth’s own desire for greatness is motivated in large part due to his wife’s passionate influence. Lady Macbeth appears to be the dominant partner in the twisted and power driven relationship between herself and Macbeth. She demonstrates her great concern with her husb... ...nglish society, Shakespeare places his female characters at the center of the action, making them equally important, if not more important than their male counterparts. These women, especially, allow the audience to view gender roles and gender restrictions imposed by society in a new light. Perhaps women are not as frail, dim-witted, and incapable as once thought. Shakespeare seems to lead us to the idea of women holding significant yet distinctive roles in society. He has effectively created strong, independent women who do not accept traditionally prescribed gender roles, but instead speak what they will, when they will, and do what they deem best. Through their distinctive actions, each of these women presents alternatives to the traditional patriarchal values of the time period as they establish themselves as thinking, feeling, and essential members of society.

Hybrid Electric Vehicles Essay

Hybrid cars are thought to be the vehicle of the future, with increasing emphasis being put on cutting carbon footprints and protecting the planet. Not long ago Hybrid cars were the preserve of the particularly eco-conscious, but they have now made their way into the mainstream. Most major motoring brands offer Hybrids with models like the Toyota Prius, the Honda CR-Z and the Lexus CT proving popular. They work by combining a fuel engine with electric batteries, which reclaims energy when the car brakes or converts energy from the petrol in the fuel engine. However, more manufacturers are developing ‘plug in’ Hybrids, which offer the option to recharge more powerful batteries through a common household electricity socket. Hybrids are environmentally friendly One main reason drivers opt for a Hybrid over a standard car is that they want to cut the impact their motoring has on the environment. These motors are more eco-friendly as they encompass two engines – a traditional gasoline engine and an electric motor and batteries – which work together to cut fuel consumption. This makes them the car of choice for motorists who are environmentally conscious and know that opting for a gas guzzler will have a negative impact on the environment. They also have a lower running cost In tough economic times when the cost of car insurance and petrol is rocketing, people will do anything to keep the cost of their car maintenance down. Investing in a Hybrid is one way to do this. Thanks to the two-engine system Hybrid drivers will use around half of the petrol or diesel, making for fewer pricey trips to the gas station. You get road tax breaks In an effort to encourage people to be eco-friendly in their motoring practices, the government is encouraging people to drive a Hybrid by giving them road tax breaks. Depending on the carbon emissions of their particular car, drivers will either pay less road tax or none at all. Hybrids are expensive to buy in the first place While you might save on running costs, Hybrid cars tend to cost more than their equivalent gas guzzling counterparts. However, the difference tends to stand at around ? 1,000 to ? 2,000, meaning that it is very possible to make your money back in the long run. Some people are concerned about the batteries Hybrids utilise batteries and some people are worried about the toxicity of these. However, today’s models use NiMH batteries rather than the environmentally difficult nickel cadmium ones. Furthermore, these battery packs are designed to last for the lifetime of the vehicle. New parts and servicing can be inconvenient and expensive. Due to the innovative technology utilised in Hybrid cars, mechanics at traditional garages do not have the expertise to fix them should something go wrong. This means that Hybrid owners need to take their motor back to the dealer for servicing. In no way should they attempt to fix the problem themselves as there is a risk of electrocution. What’s more, because Hybrid’s are newer and rarer getting hold of new parts can be an expensive process, which can make maintenance on the car more expensive than with an older motor.

Illustrate the case for reading the poem as (in part) a study in becoming Roman Essay

To both modern and ancient readers alike perhaps one theme of the Aeneid has generally been perceived most strongly, that of the poem’s glorification and aetiological justification of the values and society of the Imperial Rome in which its poet, Vergil, lived. In contrast to the Hesiodic concept of the decline of society from a bygone Golden Age, Vergil implicitly argues in the Aeneid for the constant evolution of society as having produced in Rome the very pinnacle of civilisation. However, this does not mean that his view is universally rose-tinted: Vergil, also, manages to portray the pathos of those who give their lives for this end (e.g. the self-sacrifices of Dido in book IV and Nisus and Euryalus in book IX [at whose plight Vergil says siquid mea carmina possunt, nulla dies umquam memori vos eximet aevo1]). Like Augustus, Vergil tends to relate the present to mos maiorum, so that innovation is given the guise of conservatism (as Rome was, after all, a generally conservative society). In this essay, I shall discuss the ways in which the poem expresses the development of such a Roman identity. From the outset the poem explains that Aeneas’ struggles (with which we are first met) are not in vain: his descendants are, famously, to obtain imperium sine fine, in the words of Jupiter (1.277). By book XII, that goal is within clear sight. The fact that the all-powerful father of the gods programmatically and teleologically tells of such future greatness so early in the poem gives the reader no option but to focus subsequently on how Aeneas achieves this fated goal. Vergil tends not to involve the gods as directly in the narrative of human affairs as does Homer, but uses them to great effect symbolically and to give such weighty pronouncements. Another programmatic feature of the first book involves its emphasis on kingship: to give just two examples, at line 265 we are told, by Jupiter, that Aeneas will reign over Latium and he is soon after described as king of the fugitive Trojans by Ilioneus (544). Dido ‘is [termed] regina eleven times’ in book I.2 This may not be particularly surprising considering that kingship was the traditional form of government in epic poetry and the heroic world, but such emphasis could be said not only to foresee the supreme power of Augustus (though he did not, due to the negative connotations, style himself as rex or dictator) but also to legitimise it. Augustus may be seen as a benevolent dictator in the mould of Hellenistic kings. To become truly Roman it follows that Aeneas must, equally, become less Trojan, and we can see this process occurring in the poem. Due to the high esteem of Homer’s epics (and the relative paucity of other accounts), the Trojan world is, for both Vergil and ourselves, a predominantly Homeric one; accordingly, some critics have seen in the poem of a gradual rejection of Homeric values. For example, the Aeneas that we see in book II can be said to be ‘rash, implusive, brave [and] seeking when all is lost the glorious death’3: all perfectly Achillean attributes, which, one could argue, slowly recede as the poem progresses. In the second half of the poem (i.e. the ‘Iliadic half’), Turnus is a clear foil to Aeneas (n.b. his bellicose words to Pandarus at the end of book IX: ‘You will soon be able to tell Priam that here too you found an Achilles!’). The Roman way of life involves, arguably, a reliance on debate and compromise more than the manliness and aggression of Homeric heroes. However, this analysis cannot be treated too simplistically as there are points, even towards the poem’s dà ¯Ã‚ ¿Ã‚ ½nouement, where Aeneas is just as ruthless and cold as ever: for example, at many points during book X he rejects pleas for mercy and jeers at those who are on the point of death. Anchises’ prophetic statement in the underworld of book VI has, also, been seen by critics as important in showing both us and Aeneas how to ‘become Roman’, whilst also sanctioning the power of the Roman state: Your task, Roman, and do not forget it, will be to govern the peoples of the world in your empire. These will be your arts — and to impose a settled pattern upon peace, to pardon the defeated and war down the proud. (6.851-3) It is important to note the context, for Aeneas is now starting to act very much like the good king, by acting in accordance with the gods when he leads his men to the Sibyl; whilst in the underworld, Aeneas sees a number of his descendants and successors, many of whom are rulers, and by doing so his right to rule is implicitly confirmed. The speech of Anchises, however, sets Rome within a firm tradition: it was well accepted by many Romans that Greek culture was superior in many respects. If we look at the lines above in which Anchises mentions the Greek arts of sculpture, oratory and astronomy, he can surely be said to define Rome against Greece by tacitly accepting their superiority in these realms, but he implies that the arts of Rome, the arts of peace and war, are what really matter. Though this may seem like an exceptionally aggressive mission, the extent to which clemency (a famous virtue of Augustus) and ultimate peace are emphasised must be noted. In the light of these ideals, Aeneas’ Achillean anger towards Turnus seems ‘in this light disturbing’.4 Perhaps the ideals are too idealistic to reflect reality truly. However, whether they were actually achieved or not, the ideals seem to have been held dearly in historical Rome, if we read what Claudian wrote (albeit with some degree of bias) four centuries after the time of Augustus: This is the only nation which has received conquered people in her embrace, and protected the human race under a common name like a mother not a tyrant, has called those whom she defeated her citizens, and has united the distant parts of the world in a bond of affection for her.5 One has to consider, however, that Roman bravado is often tempered in the poem. The many Trojan deaths throughout the poem are often glorified to emphasize the individual sacrifice for the communal goal. For example, Vergil’s apostrophe to Lausus: ‘harsh death’s misfortune and your noble deeds †¦ I shall not indeed leave unsung, nor you, O unforgettable youth’. 6 Such apostrophes seem to be based upon formulae deriving from Homeric invocations of the Muse, however, which might imply that the sentiment is not so personal as it seems.7 Dido, too, is seen as merely another obstacle which needs to be overcome for Rome to flourish (though she is repeatedly described, perhaps in Vergil’s own voice, as ‘pitiable’). Indeed, in one startling way she could be said to resemble a disgraced Homeric warrior: she falls on her own sword. Aeneas’ ‘escape’ from her thus further represents his retreat from Homeric values. To look at one final such death, the final two lines of the poem focus on the death of Turnus: The limbs of Turnus were disolved in cold and his life left him with a groan, fleeing in anger down to the shades. (12.951-2) The coldness of Turnus’ body may recall in our minds the first storm scene in which we meet Aeneas at sea, and may reiterate the degree to which Aeneas has reversed his despair (turning it into the despair of his main adversary). These lines thus emphasize both the pathos of the death and the certainty of Aeneas’ victory. It recalls, and is based upon, Homer, i.e. the deaths of both Hector and Patroclus (Iliad 16.857 & 22.363).8 The sadness of his death is thereby emphasised, since he is equated with such heroes on either side of the Trojan war. His death was a natural end to the poem (though perhaps an unnatural end for him). It may now be useful to look closely at a part of the poem that is, undoubtedly, looking forward to Rome perhaps more explicitly than any other: the ecphrasis towards the end of book VIII (626-728) focusing on the shield of Aeneas wrought for him by Vulcan as a foresight of the coming Roman glory. However, the crucial intertext on which this scene was modelled is that of the ecphrasis on Achilles’ shield at Iliad 18.478ff, so Vergil is still using a Homeric model to emphasise Rome’s greatness; Greek epic has such gravitas as a genre that, if Rome is to be such a towering civilisation, Roman epic needs to look back to its Greek antecedent. Indeed, in Homer Achilles has a desperate need for new armour (with the loss of his own after the killing of Patroclus), whereas it seems that Vergil includes this scene merely to show ‘before the full-scale fighting begins, what is to be achieved by it’. 9 The final, and (both literally and symbolically) central, scene of the shield shows Augustus’ celebrations after the battle of Actium (31 BC) in which he gained imperium from M. Antonius. Indeed, the shield itself is reminiscent of the shield that was hung in the Curia to commemorate Augustus’ virtues in 27 BC; such virtues (i.e. virtus, clementia, iustitia and pietas) surely apply equally to the Roman imperator and Aeneas (especially pietas, since Aeneas’ pietas was proverbial and pius is a common epithet applied to him throughout the poem). The two men are poetically conflated, thereby giving heroic prestige to the emperor. Most pertinent, however, is that the scene shows numerous and various peoples of the earth (e.g. Nomads, Scythian Gelonians, Gaulish Morini etc.) offering Augustus gifts: the implication is clearly that virtually everyone throughout the world is universally thankful for the arrival of pax Romana. The message is not quite so clear-cut and confident, however, since the theme of war is also almost always present in this vignette. Quite obviously, the theme of ‘war is apt both for the Shield as a martial instrument and for the circumstances of its delivery’,10 however, it moreover emphasizes the extent to which Roman peace relies upon the willingness to fight, however counter-intuitive that might seem. Virgil is certainly patriotic, but he nevertheless neither shies from or tries to obscure the realities of the early-Imperial political situation. In conclusion, the Aeneid can clearly be seen as a study in becoming Roman. Aeneas’ divine mission is reiterated throughout the poem with increasing intensity, especially throughout religious symbolism and prophecy: Aeneas is well aware that he must become Roman. The poem appears to move towards Roman values as it progresses, values such as pietas and clementia, in the face of Homeric impulses and aggression. However, such an analysis needs to be tempered: most notably because of such incidents as Aeneas’ rage against and murder of Turnus when he sees him wearing Pallas’ sword belt. Moreover, the poem continuously looks forward to a Rome to come, especially the Augustan Rome of Vergil’s era. Some have seen the poem as a mere propaganda piece, but it is clear that Vergil’s implicit praise for the Augustan rà ¯Ã‚ ¿Ã‚ ½gime is sophisticated and not blind to the woes of war and those who are killed to make way for the Roman superpower: to use the phrase of the Aeneid, sunt lacrimae rerum. Through imitation (and innovation), Vergil also looks back to Homer. Perhaps the best summary of the message of the Aeneid is given by the ancient commentator Servius: ‘Virgil’s intention is to imitate Homer and to praise Augustus by means of his ancestors.’11 Vergil may, ultimately, have succeeded in his aim, when we consider that the poem was considered a seminal text in Roman civilisation and acquaintance with the poem was a primary method of teaching ancient children not only Latin but also the ‘Roman way of life’. Bibliography Cairns, F. (1989). Virgil’s Augustan Epic. Cambridge. Hardie, P.R. (1986). Virgil’s Aeneid: Cosmos and Imperium. Oxford. Lyne, R.O.A.M. (1987). Further Voices in Vergil’s Aeneid. Oxford. Williams, R.D. (1985). The Aeneid of Virgil: A Commentary. London. Williams, R.D. (1990). ‘The Purpose of the Aeneid’ in Oxford Readings in Vergil’s Aeneid (ed. S.J. Harrison), Oxford. 1 Aeneid 9.446-7. 2 Cairns (1989), 2. 3 Williams (1990), 28. 4 Lyne (1987), 112. 5 Cairns (1989), 205. (De Consolatu Stilichonis, 3.150-3.) 6 Aeneid 10.791-3. 7 Lyne (1987), 235. 8 Lyne (1987), 135-6. 9 Williams (1985), 90. 10 Hardie (1986), 347. 11 Williams (1990), 21.