Goodman Essays - Young Goodman Brown, Goodman,

Goodman What is theme? Theme is what the author is saying about the subject of the story. In "Young Goodman Brown" the subject of the story is hypocrisy. In "Young Goodman Brown", Hawthorne writes in detail how hypocrisy can change a person for the worse. In the opening pages of the story you can see how hypocrisy is already starting to change Goodman Brown for the worse. As he starts out on his errand that he has to run, Goodman Brown decides to walk as Hawthorne puts it "A dreary road darkened by all the gloomiest trees of the forest, which barely stood aside to let the narrow path creep through, and closed immediately behind." (141). The forest is an important symbol in this story. The forest symbolizes evil and it symbolizes evil because of the darkness of the forest. As Goodman Brown and his companion continue their journey through the dark forest Goodman Brown starts to realize this "errand" that he is running is no ordinary one. Goodman Brown knows that he is doing something scorned down on by Puritan beliefs as he says the following: "My father ever went into the woods on such an errand, nor his father before him. We have been have been a race of honest men and good Christians since the days of the martyrs. And shall I be the first of the name of Brown that has ever took this path and kept." (141). So basically what he is saying in that quote is that he knows what he is doing is wrong, but he doesn't care. Goodman Brown is hard to convince that his family and the Puritans in general are not as righteous and pure as he thinks they are. The companion tries endlessly to convince Goodman Brown that his own family is not as "pure" as it seems. The traveler tells Goodman some stories of his own family doing dirty things such as setting fire to an Indian Village and lashing a Quaker woman. However Goodman does still not believe any of what the traveler is saying. Continuing on the path Brown and his companion stumble upon Deacon Gookin and his Goody Cloyse and Goodman is astonished by this because he would have never thought that the good wife would be so far in the forest that late at night. By seeing the good wife in the forest at that time of night makes Goodman not want to go on. While sitting on a stump, Goodman yells out "Friend, my mind is made up. Not another step wills I budge on this errand. What if a wretched old woman choose to go to the devil when I thought she was going to Heaven! Is that any reason why I should quit my dear Faith and go after her?" (143) Basically he is quitting what the errand because he senses that what the companion has told him is to eat at him. In other words the hypocrisy is starting to enter his soul and he is trying to keep it from doing that by stopping the journey. Another example of what Hawthorne is saying about hypocrisy in the story is the part where Goodman hears what the Deacon says as he passes by in the carriage. Goodman is astonished by the words he hears coming from the carriage. Also Brown is amazed that the Deacon would have traveled that far into the dark and dreary forest. As Hawthorne puts it "Young Goodman Brown caught hold of a tree, for support, being ready to sink to the ground, faint and over-burthened with the heavy sickness of his heart. He looked up to the sky doubting whether there really was a Heaven above him." (144) Basically Goodman cannot believe what he just heard from the leaders of the Religion of the puritans; he is amazed that impurity lies within the most religious people of the Puritans. It makes him believe what the companion told him about pureness. Seeing all of this makes him say that if no one else wants to stand true to the beliefs of the puritans, not even the Deacon himself, then he was going to be the one who does. Moreover witnessing all of that Goodman finally understands that purity is no longer what all mankind strives for. As Brown stands their he looks up to see what was once a blue sky has suddenly turned gray. This Gray sky symbolizes the impurity or hypocrisy that has taken over the earth. Goodman also

Alone Together Professor Ramos Blog

Alone Together Have you ever felt alone, even for just a split second? If you ever read any of Sandra Cisneros’ work, you can constantly see the theme of loneliness throughout many of her short stories. Perhaps this theme stems from her life of always being alone. During an interview with Pilar E. Aranda Rodriguez for The Americas Review, Mr. Rodriguez asked Cisneros why she has never married. Cisneros replies, â€Å"Ive never seen a marriage that is as happy as my living alone. My writing is my child and I dont want anything to come between us† (Rodriguez). She seems very comfortable with being alone, yet in the stories she portrays how loneliness is actually supposed to feel like. In the stories â€Å"There is a Man, There is a Woman,† â€Å"Woman Hollering Creek,† and â€Å"Never Marry a Mexican,† one can see how they are all connected through the theme of loneliness, but each character hides their feelings with their actions. The way loneliness is portrayed in the short story â€Å"There is a man, There is a woman† can be expressed through the characters’ everyday life. The man and the woman’s friends cannot see how they truly feel and how hurt they are. For example, when the man and the woman drink with their friends on Friday’s, they drink hoping they would say something but never say it (Cisneros). Maybe they are trying to express how lonely they feel, yet they can never open up to close friends. Its hard to believe how people could be doing the same thing right at the same moment, in the same place but they will most likely never meet. Although the man and woman share the same actions whenever there doing something, it seems very cruel that they will never know about each other. The theme of this story revolves around the idea that being alone doesnt always mean that you are really alone because someone out there can be feeling the same thing you are feeling. In other words , your connected through the sense of loneliness.   In the story titled â€Å"Woman Hollering Creek,† loneliness is hidden through the violence of Cleofà ­las marriage. Being alone seems to be growing upon the main character, Cleofà ­las, as the story goes on. In the beginning of â€Å"Woman Hollering Creek,† it is as if Cleofà ­las is living that great way of life as all other great marriages. She was getting married, having a child, moving to another country, and everything seems to be going well. That is until her husband started to beat her. When he first hits her, she thought that the next time he did, she would do something about it. Yet, she never had it in her to defend herself. Then every time she gets hit, she progressively feels lonely as if her happiness was just what you feel in the start of the marriage. Than her true emotions begin to overwhelm her. Even after having one child and being pregnant with another, Cleofà ­las can feel less and less close to the man she married as if he just a fake lover. Al one with her kids she would push herself to do the unthinkable and would finally leave her husband. In spite of Cleofà ­las’ feeling of happiness and gratitude toward her children, she cannot hide how truly lonely she has become through her marriage. It’s clear how this story also shares the theme of loneliness, but is hidden with the characters actions.   Finally, the last story that takes part in the theme of loneliness is â€Å"Never Marry a Mexican.† This is a complicated story that is nevertheless a sad or appalling one, depending on your point of view. The writing is basically about a woman named Clemencia who enjoyed sleeping with married men. Although you could argue that she picked this up from her mother since the mother cheated on her dying husband when Clemencia was young, yet Clemencia is still an adult and has the option to say â€Å"no† to every situation. You can also argue that she was targeted by married men, but could have rejected them. Perhaps she feels like she needs to make bad decisions in order to feel less alone. Her first affair occurred while she was in college with a Professor who was married. Clemencia would grow to love this Professor but she knew that she would never truly be happy with him because as a young child, she saw from her mom that there was no such thing as true love. So, after d enying the Professor of his offer to leave his wife for her, she would later regret her decision and try to fix her mistake but it was already too late because the Professor would never see her the same way again. Clemencia would then want revenge so she waited years to sleep with the Professors son. Throughout the whole story, Clemencia constantly enjoys her way of her life yet, she’s also trying to find love but was not able to. Even at the end of the story she said â€Å"I just want to reach out and stroke someone, and say There, there it’s all right, honey. There, there, there† (Cisneros). Clearly, she wanted to be with some but was truly alone. As if her purpose was just to create holes in marriages because she had no way of actually dealing with being lonely. As you can see, loneliness is a significant theme in this story but Clemencia covers this feeling up with her terrible deeds.   Being alone can be a very brutal thing. It is as if you were born just to be born and to never know a person that is close to you, without you even knowing. In other words, you feel like you have no purpose but there is someone out there that feels exactly the same way, you just might never meet because of the path you are in. You could say that its fate or just bad luck. In the end you still feel that empty spot in which someone is going to fulfill one day, but has not fulfilled yet. The thought of never understanding why you still feel lonely builds more and more whenever you think of your state of being alone. Almost as if the wound that was created by your past actions makes you more careless yet, scares you at the same time. That unwanted thought of being alone fills your mind and changes the way you look at life. In the stories â€Å"There is a Man, There is a Woman,† â€Å"Woman Hollering Creek,† and â€Å"Never Marry a Mexican,† each main character has a way of covering up their loneliness through their actions such as drinking with friends, pretending to think ones marriage will change, or sleeping with married men. Which concludes that loneliness plays a great deal on how people act in certain situations. Perhaps the only way of stopping this feeling of loneliness is through companionship, which each character is seeking. Bibliography Cisneros, Sandra. Woman Hollering Creek and Other Stories. First Vintage Contemporaries Edition, March 1992, Kindle Cloud Reader, read.amazon.com. Rodrà ­guez Aranda, Pilar E. â€Å"On the Solitary Fate of Being Mexican, Female, Wicked and Thirty-Three: An Interview with Writer Sandra Cisneros.† The Americas Review, 1990, pp. 65–80.

A Reflection of My Mother Essay Example | Topics and Well Written Essays - 1500 words - 1

A Reflection of My Mother - Essay Example We all knew he loved us but he wasn’t a very affectionate person that always gave out hugs and kisses. Before I knew it, I was the official babysitter, watching my own sister and brothers, feeling like the mother goose. Growing up with a lot of responsibility, I was brought up to be resourceful and to never waste food. Being a middle-class family, my mom was a little frugal and taught us to make goals and to stick to them. I was very involved in sports to stay out of trouble and planned around my sister and brothers functions so that we can all be home together at the same time. She also told us to never take pity on ourselves for the cards we have dealt; it happened, so now we should move on. We all learned to have respect for the elders and to help one another. I benefited from my childhood because it, and my parents, helped to set the foundation for the person I wanted to be when I grew up. I watched and studied how my parents, especially my mother, handled things and lived her life, and I strived to be just like her. I figured that if she could do a good job being the person that she was, then I could be the same way. The love that she had for others really inspired me to be just as loving and as giving. Today, I have two children of my own, a daughter who is seven and a son who is eight years old and they both demand a lot of my attention. With all the years of training I received when I was younger, it just seems to come naturally to me. I work hard, apply myself and volunteer to help others. I do not always have the time, but I do try to make time. Another important quality I find in myself is that I do care for everyone, family or strangers. I volunteer to donate blood/platelets to help the people and cancer patients who need it. I sometimes find myself crying in front of the television over a commercial, feeling so happy or sad for that person.  Ã‚  

A Road Not Taken Poetry Explication Essay Example | Topics and Well Written Essays - 750 words

A Road Not Taken Poetry Explication - Essay Example Then in November 8, 1894, The Independent newspaper of New York published his first ever professional poem. In 1985, Frost married his long time girlfriend and fiancee Elinor Miriam White. She proved to be a significant inspiration in Frosts poetry until her death in 1938. The couple had moved to Britain in 1912 after a failure of their New Hampshire farm. It was there that Frost met other modern day poets as Rupert Brooke, Robert Graves and Edward Thomas who inspired and motivated him. While there, Frost also found friendship in poet Ezra pound who contributed to the promotion and publication of Frost’s work. At the time, of his return to the United States in 1915 Frost had published two full collections, North of Boston and A Boy’s will which had established his reputation as a re-known poet. Frost went on to become the most celebrated poet in America increasing his fame and honors with each new book. Though his work was some-what of traditional form and by principle associated with life of New England, Frost is merely a neither minor nor regional poet. The author of mystical and often searching themes, Frost is a modern poet in how he adhered to language and the complexity of his work through its layers of irony and ambiguity. Until his death in Boston on January 29, 1963, Robert Frost taught and lived in Massachusetts and Vermont for years. The road not taken is a metaphorical poem relating to the period and the amount of consideration it takes an individual to make a momentous decision. In reference to Frost’s biography, he made decisions that turned his life around totally. In the poem, the road not taken uses the path as a general metaphor for his life. He starts. â€Å" Two roads diverge in a yellow wood†(Line 1) Here Frost introduces the metaphorical two roads which are primary to the poem. â€Å"And sorry I could not travel both And be one traveler, long there I stood.† (Lines 2 and 3)According to the phrase Frost is trying to explain to us that we find ourselves in situations where necessity dictates it for us to make decisions. Where we have to choose this over the other, some of us spend quite a substantial amount of time deliberating over things, trying to trying to identify the best decision. Robert himself at one point in life made the decision to quit Harvard. He went to live on his farm with his wife to concentrate more on his poetry writing. In the process of making this decision, he must have deliberated on what is best for him and what makes him happy. In this stanza of the poem, Robert Frost writes that he is at a crossroad where he has to choose which way he was going to embark on, to continue with his journey. Day after day we find ourselves in situations where we need to make choices. Some involve little things others might change our lives wholly, thus the need to take our time to think about what would be the decision in relation to our lives. This stanza aptly explains this ph enomenon, since Frost describes how he is at that intersection for a long while trying to decide which path would serve him best. When we look at the second stanza Frost also writes â€Å"Then took the other, as just as fair.† (Line 1) Frost explains how he gave both paths an equal amount of thought and concentration. Frost continues to explain his actions by asserting that one should not look at his or her choices without carefully thinking things over.

1st Amendment Essay Example | Topics and Well Written Essays - 500 words

1st Amendment - Essay Example Freedom of speech should also be limited whereby one takes away someones rights such as threats and discrimination. Freedom of speech should also be limited for matters of national security whereby information shared should be confidential( Freedom of Expression in the United States, 2013) Yes, freedom of speech can improve society. Freedom of speech allows citizens to freely criticize the government which responds to answer to its actions unlike whereby speech is restricted, unfair criticisms tend to rise and may spread all over the country. Freedom of speech gives the society political right which allows them to resist to oppression, injustice and have free elections. Freedom of speech allows citizens to freely express their minds on vital issues of the society and access information which promotes the free flow of thoughts that preserve democracy and self-actualization for the healthy development of the society. Pure freedom is speech is not beneficial in todays world since unlimited freedom of speech is damaging to the development of the society and the government service to its citizens. In scenarios whereby speech is unlimited, unfair criticisms are made against the state in which case the state cannot respond. This results in poor relations between the state and its citizens and its a step backwards to national development. The modern society often abuses the freedom of speech to hurt and harm others. For example; Television stations, air adult content without putting a warning message and minors end up being exposed to indecent material. They should be limited to airing those programs at later hours. No, allowing people to freely spread hatred, incite violence and ridicule others religions and nations results in a divide and lack of peace between the people, different religions and countries. It also violates the freedom of speech, freedom of expression and the right to

Using gentamicin in the management of sepsis

Using gentamicin in the management of sepsis Sepsis is defined as the inflammatory response toward an infection (1). It is either simple or severe sepsis depending on the organ dysfunction involved as a result of the infection and other factors (2). In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death (3). In terms of definitions of other sepsis-associated symptoms, it was generally agreed at the International Sepsis Definitions Conference which was convened in 2001 and the following definitions of sepsis syndromes were published in order to clarify the terminology used to describe the spectrum of disease that results from severe infection. Sepsis is the presence of infection in association with meeting the Systemic inflammatory response syndrome (SIRS) criteria (Box 1 (2)). The clinical significance of meeting SIRS criteria in the absence of organ dysfunction or shock is still unclear. Severe sepsis is defined as evidence of end-organ dysfunction such as altered mental status, episode of hypotension, elevated creatinine, or evidence of disseminated intravascular coagulopathy. Septic shock is defined as persistent hypotension despite adequate fluid resuscitation or tissue hypoperfusion manifested by a lactate greater than 4 mg/dL. Bacteremia is defined as the presence of viable bacteri a within the liquid component of blood (1). Acute pyelonephritis is defined as an acute infection of one or both kidneys; usually, the lower urinary tract is also involved (4). Antibiotic regimen of choice for Sepsis that is associated with urinary tract infection is Co-amoxiclav 1.2g 8 hourly intravenously together with Gentamicin IV dose of 5mg/kg once daily (5). Although that is controversial whether to use the ideal body weight (IBW) or to obtain blood samples indicating Gentamicin level to get the optimal dosing regimen for Gentamicin in obese patient due to risk of accumulation with Aminoglycoside and the fear of oto- and nephrotoxicity (6). Other supportive measures depend on the patients status; table 1 (1) contains helpful measures that indicate markers of organ dysfunction. Case Summary Our patient, C.M., is a 56 years old female who was admitted to the Accident and Emergency department (AE) due to an increased urinary frequency and a high temperature of 40.5 °C. Other complaints were back pain and shortness of breath (SOB). Also, the patient had reported a fall the night before admission. Moreover, the patient had vomited the night before and in the morning of admission. C.M. is a previous smoker who had stopped smoking several years ago and she lives with a partner. She is clinically obese weighing 100kg and her height is 152.4cm. Giving this, her ideal body weight (IBW) comes to 49kg. The only known allergy for this patient is microspores tapes. The patients past medical history (PMH) included asthma, non-insulin dependent diabetes mellitus (NIDDM) and fibromyalgia. She was on one puff daily of each Symbicort Turbohaler 200/6  µg and Ventolin Accuhaler for the management of her stage 3 asthma. Metformin 1g daily was prescribed for her diabetes control; however, its formulation was not mentioned (whether it is a sustained release tablet or a normal release one!). For her fibromyalgia, she was taking 300mg of Quinine sulphate daily together with 150mg of Amitriptyline daily (which is a very high dose; low dose of tricyclic antidepressant (T CA) is recommended i.e. 20-30mg of Amitriptyline). For her pain, the patient was on Co-codamol tablet as required (strength, dose and frequency were not mentioned). Having that she is a diabetic patient over 40 years old, a dose of Simvastatin 40mg daily was prescribed as a primary cardiovascular disease (CVD) protection measure. In addition, Omeprazole 20mg daily was one of her regular m edications with unclear indication. Investigations On admission, an Electrocardiography (ECG) was performed and indicated sinus tachycardia; which could be related to the high temperature, pain or sepsis. The patients vital signs were abnormal having a respiratory rate (RR) of 22 breaths per minute (normal is ~ 12bpm), a heart rate (HR) of 117 beat per minute (normal is ~ 70bpm) and a blood pressure (BP) of 142/65 mmHg (target for diabetic patients is Her laboratory investigations were almost normal except for some parameters. The Sodium level was a bit low which could be a result of the frequent urination or an Amitriptyline hyponatremic effect. Glucose and C-reactive protein (CRP) levels were high which might indicate the presence of infection. Thrombocytopenia may be caused by Quinine or Simvastatin administration! Impression and related Management Plan The patient was diagnosed as a pyelonephritis and sepsis case; so empirical antibiotic regimen was initiated with 1g Amoxicillin intravenously six hourly and 500mg ciprofloxacin orally once daily. Also, 1g Paracetamol intravenously six hourly and one liter Normal Saline intravenously over 24hours was started. Urinalysis on the first day indicated the presence of leucocytes, nitrites, glucose, ketones and blood which means a presence of infection. On the second day, blood culture showed a growth of E. coli which is sensitive to Gentamicin, therefore, 400mg Gentamicin intravenously every 24 hour was prescribed and ciprofloxacin was discontinued. Gentamicin plasma level was requested 6-14 hours after administration of the first dose. In addition to the patients regular medications, 50 mg of Cyclizine eight hourly and 20mg of Citalopram once daily were added, paracetamol IV was switched to orally in the second day and 30mg of oral codeine as required was prescribed ; but the patients Salbutamol Inhaler had been stopped for unclear reason. Discussion Revising the management plan for this patient and in comparison to the local guidelines for the management of pyelonephritis and sepsis patients, we would notice that 1.2g intravenous Co-Amoxiclav is the first-line choice of Penicillins, not Amoxicillin, together with Gentamicin. However, if the ideal body weight is required to obtain the appropriate dosing of Gentamicin for obese patients, so in this case, 245mg of Gentamicin supposed to be prescribed instead of 400mg which is the maximum daily dose (Although that some infectious diseases specialist would recommend going to the maximum dose to make sure that we get the maximum benefit; but we must consider patient status and severity of infection!). Also, it is essential to check the optimal timing for monitoring each drug plasma level, in our case, Gentamicin therapeutic drug monitoring (TDM) has not deviated from the local guidelines recommendation for the once daily dosing of Gentamicin i.e 6-14 hours after giving first dose. Having a patient with increased urination and vomiting, we must consider fluid replacement. Replacing with one liter Normal Saline (NS) might have not met the patients requirement! So it is recommended to check patients need to ensure appropriate replacement i.e. at least 2.5-3 liter daily. We could have recommended giving 2 liter NS each over 8 hours plus the addition of 500ml 5% Dextrose to ensure calories intake if the patient cannot tolerate oral intake. Considering the patients asthma control, we must confirm that Salbutamol inhaler was not mistakenly missed after admission. Since that SOB was one of the patients complaints, we must ensure that it was relieved, if not, consider 5mg of Salbutamol nebulizer four times daily to be added to the regimen and if nebulizer is not necessary, ask for Salbutamol inhaler to be charted as if required basis (6). Also, blood gases were not mentioned so it is probably safer to ask for the oxygen and carbon dioxide saturations to consider if oxygen therapy is needed! Confirm that the patient and nursing staff are aware of inhalers techniques. The patient is on Amitriptyline 150mg orally daily which is considered an old practice for the treatment of fibromyalgia (high dose TCA) and the current recommendation states 20-30mg of Amitriptyline daily for 8 weeks (6) so it is better to re-consider dosing or to change regimen. Low dose Sertraline or high dose Venlafaxine therapy may be effective (6) so consider changing if no further benefit of the use of Amitriptyline. For the associated pain, Paracetamol with Tramadol has better efficacy than Co-codamol. Pregabalin (150-300mg every 12 hours) may improve pain especially if combined with Tramadol; it also improves sleep and morning stiffness (6). So, knowing the patients control with the current medication would be helpful to consider treatment change or modeling to get the most of pharmacologic treatment. Suggesting alternative ways to manage symptoms is also recommended, e.g. spa therapy, physiotherapy, stress management, acupuncture or diet (6). NICE guidelines for the management of type II diabetes mellitus state that Metformin is the first line choice for obese patients. Choosing appropriate formulation that suits the patients lifestyle is essential to ensure patients compliance. Once daily dosing of sustained release formula could provide 24 hour control over glucose, but in this case the present of infection interfered with having accurate reading so it is logical to check the HbA1c to check the glycemic control over the last 8 weeks to consider any therapy modification. Also, pre- and post-prandial glucose level monitoring is required to avoid both hyper- and hypoglycemia using the current regimen. Statins must be prescribed for all diabetic patients who are over 40 years old (6) and having any risk factor of Coronary Vascular Diseases (CVD). The patient was on Simvastatin 40mg daily but no Cholesterol level obtained (consider Ezetimibe if high Cholesterol). Monitoring liver function tests (LFTs) and any muscular side effect is important. Also, having a high BP on admission, checking that BP is normal after sepsis reveals is vital. If persistent high BP, consider adding ACE inhibitors, having the benefit of BP control and protecting the heart in patients susceptible to Vascular Diseases. Weight loss in this patient is advisable so consider dietitian and physiotherapist review to consider going on diet and exercise. Also, annual eye check is recommended to control retinopathy due to DM. Cyclizine was prescribed on regular basis, so we better check if the patient is really on need of a regular anti-emetic, otherwise, consider changing it to as required basis. Regarding Paracetamol, it was prescribed on as needed basis but it was not put clear not to exceed the maximum daily dose, so it is recommended to clarify that to not give the patient more than 4g per day. It is safer to contact the patients GP to confirm the indication of Omeprazole and to consider discontinuation if no clear indication was obtained. Additionally, the patient was thrombocytopenic, which could be a side effect of administration either Quinine or Simvastatin, so monitoring the platelets count is highly recommended to prevent any complication, although DVT prophylaxis is not needed as long as the patient is mobile. Conclusion In conclusion, the overall patient management had no much deviation from the current guidelines recommendation except for some practice that need to be reviewed considering the current patients status. Therapeutic monitoring should be carried on because the patient is under risk of many complications or side effects. Lastly, patients awareness of her clinical condition and treatment requirement for each problem is helpful to prevent or reduce future health problems. Appendix 1: PATIENT MEDICATION PROFILE Patient details Name C.M. Consultant General Practitioner Address Gender Female Weight 100 kg Height 152.4 cm Community Pharmacist Date of Birth (Age) 56 y.o. Known Sensitivities Micropores tapes Social History Previous smoker, lives with partner Patient hospital stay Presenting complaint in primary care / reason for admission Admission date 2008 Increased urinary frequency Back pain Shortness of breath Vomiting Fall (the night before) Fever (40.5 °C) Discharge Date Discharged to Relevant medical history Relevant drug history Date Problem Description Date Medication Comments Asthma Symbicort 200/6 Turbohaler 1 puff daily Ventolin Accuhaler 1 puff daily Non-insulin dependent diabetes mellitus Metformin 1g daily Formulation? Fibromyalgia Co-codamol PRN Strength? Amitriptyline 150mg daily Too high! Quinine sulphate 300mg daily Duration? Simvastatin 40mg daily 1ry CVD prevention Omeprazole 20mg daily Indication? Relevant non drug treatment Prescribed Medication Start Stop Clinical/Laboratory Tests Result 1 Paracetamol 1g IV 6 hourly Day 1 Day 2 ECG Sinus tachycardia 2 0.9% sodium chloride 1000ml IV over 24 hours Day 1 HR 117 bpm 3 Amoxicillin 1g IV 6 hourly Day 1 BP 142/65 4 Ciprofloxacin 500mg PO OD Day 1 Day 2 RR 22 bpm 5 Metformin 1g PO OD Day 1 Urine analysis Leucocytes, nitrites. Glucose, ketones, blood +ve 6 Omeprazole 20mg PO OD Day 1 Blood culture E. coli 7 Quinine sulphate 300mg PO OD Day 1 Na 134 (135-145) 8 Simvastatin 40mg PO OD Day 1 CrCl 145.3 (78-120) 9 Amitriptyline 150mg PO OD Day 1 Glucose 8.9 (3.9-5) 10 Symbicort 200/6 inhaler 1 puff daily Day 1 CRP 180 ( 11 Codeine phosphate 30mg PO PRN Day 1 Bilirubin 35 (3-16) 12 Citalopram 20mg PO OD Day 1 PT 17 (12-15) 13 Cyclizine 50mg PO 8 hourly Day 1 APTT 39 (20-30) 14 Gentamicin 400mg IV 24 hourly Day 2 Platelets 70 (150-400) 15 Paracetamol 1g PO PRN Day 2 Clinical management Diagnosis Pharmaceutical Need Pyelonephritis Evidence-based treatment Sepsis Treatment according to guidelines Care Issue/Desired Output Action Output Confirm drug history + reconcile drug history Ask patient how and when she takes her medication and the indication for each medicine. Compare with GPs DHx + Phone GP for indications for amitrip., omep. and quinine, and when they were initiated. All regular meds have been charted except prn salbutamol. Patient is SOB; advise Dr to chart it prn. Confirm antibiotic regimen for pyelonephritis/sepsis in addition to TDM Check the local guidelines that amoxicillin is first-line for the indication (culture sens. to gent.).Calc. her ideal body weight and CrCl.Calc. gent. dose based on ideal body weight and compare to 400mg iv od (max dose).Check local guidelines whether 6-14 post dose gent. level is correct procedure. Chase level. Monitor BP, Temp, Pulse, RR for signs of resolving sepsis whilst on current regimen. Co-amox 1.2g iv tds is first-line with gent 5mg/kg (max 400mg, ideal body wt 49kg, CrCl 71ml/min). Recommend switch to co-amox because she needs 7/7 iv + oral. Recommend 245mg gent iv od Obtain level before 2nd dose is given+TDM for gent is correct. Review need for gent in 48h Fluid requirements possibly not being met by 1L N. saline in 24hours Request a running fluid balance chart due to vomiting + increased urinary frequency. Ask patient if she can tolerate oral liq. or if feels thirsty. Assess if iv is necessary (2.5L daily + replace losses) Advise doctor to amend first bag to 8 hours and chart 1L N.saline over 8hours + 500ml glucose 5% over 8 hours if patient cant tolerate oral liq. Is her current SOB being treated appropriately? If patient is still wheezy, ask for PaCO2 + PaO2. Request salbutamol nebs 5mg qds + O2 60% to be charted. If not currently SOB, ask for accuhaler to be charted prn. Assess inhaler technique for both inhalers when breathing ok Is her fibromyalgia regimen in-line with current evidence? Check Brit. Soc. Rheum for current guidance on fibromyalgia. Check that citalopram is the SSRI of choice in fibromyalgia since it has been started on admin. Review quinine; if has been in use for 3 months with no benefit consider stopping it High dose TCA is an old practice; current evidence states 25mg/day for 8 weeks. Advise a review of Amitrip. Low dose sertraline has better evidence for use in Fibro. Advise switch + show evidence to prescriber. Tramadol with paracetamol has better efficacy than co-codamol. Suggest trial switch and monitor for dizziness due to recent unexplained fall. Consider pregabalin. Lifestyle advice: stress management, diet, physiotherapy/massage, etc. Is her type II diabetes under control? Check SIGN guidelines on diabetes for current management. Request HbA1c test to determine control over last 2-3/12 Monitor glucose pre/post-prandial and random. Ask patient how she takes the metformin and how regularly Metformin is first-line in obese type II. From lab results, assist endocrinologist in determining whether metformin dose should be increased + which preparation suits patients lifestyle. Is her CVD primary prevention needs being met? Check SIGN guidelines on CVD primary prevention. Check BP + Cholesterol. Next UEs ask for urine albumin + protein levels. Ask patient about current diet and exercise plan (obese) + last eye test. Simvastatin 40mg charted. Check cholesterol. If it is high, may need ezetimibe 10mg od. LFTs ok BP 142/65, upon resolving sepsis recheck BP and initiate ACEi if appropriate. Advise dietician review (obese) + physiotherapy review (or GP) for plan (30mins exercise 5/7). Advise eye test once a year Regular cyclizine may be unnecessary Endorse chart for paracetamols maximum daily dose Reassess patients need for a regular anti-emetic and re-chart cyclizine as prn instead of regular if required Max 4g in 24 hours (e.g. 1g QDS) Highlight patients thrombocytopenia No need for DVT prophylaxis if patient is mobile. Mention that quinine or simvastatin could be the cause of low platelets. Suggest trial withdrawal of quinine if not planning on stopping anyway. Monitor Platelets level if continued. Indication for omeprazole Determine indication from GP and patient. Consider trial withdrawal if indication unknown. Appendix 2: Box 1. Consensus Conference of the American College of Chest Physicians and Society of Critical Care Medicine definitions for the various manifestations of infection.   Ãƒ ¢Ã¢â€š ¬Ã‚ ¢ Systemic Inflammatory Response Syndrome (SIRS): Manifest by two or more of the following conditions: 1. A temperature >38oC or 2. A heart rate >90 beats per minute 3. A respiratory rate >20 breaths per minute or a PaCO2 4. A white blood cell count >12,000/mm3 or 10% immature forms. à ¢Ã¢â€š ¬Ã‚ ¢ Infection:Microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by these organisms. à ¢Ã¢â€š ¬Ã‚ ¢ Bacteraemia: The presence of viable bacteria in the blood. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Simple): The systemic response to infection, manifested by two or more of the SIRS criteria pus an infection. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Severe): Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. à ¢Ã¢â€š ¬Ã‚ ¢ Septic shock: Sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that the perfusion abnormalities are measured. This is a subset of severe sepsis. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis-induced hypotension: A systolic blood pressure 40 mmHg from baseline in the absence of other causes for hypotension. Adapted from Bone RC et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101: 1644-1655. Appendix 3: Table 1. Clinical and laboratory markers of organ dysfunction. Organ System Clinical Laboratory Cardiovascular Tachycardia Hypotension Cardiac arrest Arrhythmias Haemodynamic support Altered CVP, PCWP Reduced cardiac output Endocrine Weight loss Hyperglycaemia Hypoalbuminaemia Haematological Bleeding Thrombocytopenia Increased D-dimers Abnormal white cell count Abnormal clotting profile Gastrointestinal Ileus GI bleeding Acute pancreatitis Acalculous cholecystitis Decreased intestinal pH Elevated amylase Hepatic Jaundice Hyperbilirubinaemia Increased PT Elevated LFTs Hypoalbuminaemia Neurological Delirium Confusion Altered consciousness Altered EEG Renal Oliguria Anuria Renal replacement therapy Elevated creatinine Elevated urea Respiratory Tachypnoea Cyanosis Mechanical ventilation PaO2 SaO2 PaO2/FiO2 Immune Pyrexia Nosocomial infection Altered white cell count Impaired white cell function Adapted from Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Crit Care Clin 2000; 16: 337-352.

The Inevitability of School Violence: No Need for School Reform Essay

The Inevitability of School Violence: No Need for School Reform â€Å"Guns don’t kill people, people kill people,† I have often heard. We know people kill people. The real issue now is whether or not people can change people. Some are of the opinion that we are capable of doing so; by implementing new reforms and tightening school security, people are, in effect, saying they have the solutions to the problems. The violence of recent school shootings has wrought anxiety and fear in parents, teachers, and administrators across the nation. The massacre of Columbine turned a public school library into a cemetery. The shooting in Oklahoma ripped us from the comfort of a stereotypical and easily recognized threat; now popular straight-A students pull guns without black trench coats. The violence has become unpredictable and, in all cases, extremely frightening. In response to the threat, schools have engaged in extensive prevention programs, often banning book-bags, implementing dress codes, setting up metal detectors, or requiring studen ts to attend anger management classes. Such attempts at reform sound efficient on paper and may to some extent alleviate the anxieties of parents, but they are like storming castle walls with slingshots. The object of reform in this case is not tangible or always plausible. The object of reform is the human heart, the internal person. We need to understand that the problem is bigger than a trench coat or a gun; therefore, dress codes or metal detectors cannot solve it. These reforms are often vain attempts at prevention. They hinder education and provoke students. Policy makers and schools need to be aware that no simple public mandate can suffice as a solution. In response to the massacres, schoo... ...ain—is wider than the sky—†. We cannot implement a reform that will change human nature. There is no dress code that will bring self-esteem to the outcast or humble the popular. There is no metal detector that can sufficiently alert a student population to an angry and violent peer. The problem this nation faces is that of hurting hearts and minds. To present a concrete solution one must have a concrete problem, but this problem is complicated and its factors at times inexplicable. Its enormity resides in human emotion, its source as large as the capacity of the human mind. It is, therefore, as Dickinson aptly put: â€Å"wider than the sky.† Works Cited Mathis, Deborah. â€Å"Schools Fail at Stopping Violence.† The Cincinnati Enquirer 7 December 1999, Final ed./Warren: A3. Miller, Mark. â€Å"The Haunting Memories.† Newsweek 13 December 1999, Final ed./Warren: 75.