Carl Jung Theory Essay Example for Free

Carl Jung Theory EssayJungs theory divides the psyche into three parts. The first is the ego, which Jung identifies with the aw atomic number 18 mind. Closely related is the personal unconscious, which includes anything that is not presently conscious, simply can be. The personal unconscious is like most peoples understanding of the unconscious in that it includes both memories that are con lookrably brought to mind and those that render been suppressed for or so reason. But it does not include the instincts that Freud would have it include. But then Jung adds the part of the psyche that makes his theory stand out from tout ensemble differents the collective unconscious. You could c any it your psychic inheritance. It is the reservoir of our experiences as a species, a kind of knowledge we are all born with. And yet we can never be directly conscious of it. It influences all of our experiences and behaviors, most especially the delirious singles, but we only know about it indirectly, by looking at those influences.There are nearly experiences that enter the effects of the collective unconscious more(prenominal) clearly than others The experiences of love at first sight, of deja vu (the feeling that youve been here before), and the immediate recognition of definite symbols and the meanings of certain allegorys, could all be understood as the sudden conjunction of our outer reality and the inner reality of the collective unconscious.Grander examples are the creative experiences shared by artists and musicians all over the world and in all ms, or the spiritual experiences of mystics of all religions, or the parallels in dreams, fantasies, mythologies, fairy tales, and literature. A nice example that has been greatly discussed lately is the near-death experience. It seems that many people, of many different cultural backgrounds, find that they have very similar recollections when they are brought back from a close encounter with death.They spea k of divergence their bodies, seeing their bodies and the events surrounding them clearly, of being pulled through a long tunnel towards a bright lax, of seeing deceased relatives or religious figures waiting for them, and of their confusion at having to leave this happy scene to return to their bodies. peradventure we are all built to experience death in this fashion. Archetypes The contents of the collective unconscious are called samples. Jung also called them dominants, imagos, mythological or primordial images, and a few other names, but archetypes seem to have won out over these.An archetype is an unlearned tendency to experience things in a certain way. The archetype has no form of its own, but it acts as an organizing principle on the things we see or do. It works the way that instincts work in Freuds theory At first, the baby just wants something to eat, without knowing what it wants. It has a rather indefinite yearning, which, nevertheless, can be fulfil by some thin gs and not by others. Later, with experience, the child begins to yearn for something more specific when it is hungry a bottle, a cookie, a broiled lobster, a slice up of New York style pizza.The archetype is like a black hole in space You only know its there by how it draws matter and light to itself. The mother archetype The mother archetype is a particularly good example. All of our ancestors had mothers. We have evolved in an environment that included a mother or mother-substitute. We would never have survived without our connection with a nurturing-one during our times as helpless infants. It stands to reason that we are built in a way that reflects that evolutionary environment We come into this world ready to want mother, to seek her, to recognize her, to deal with her.So the mother archetype is our built-in ability to recognize a certain relationship, that of mothering. Jung says that this is rather abstract, and we are likely to project the archetype out into the world and onto a particular person, usually our own mothers. Even when an archetype doesnt have a particular real person available, we tend to personify the archetype, that is, turn it into a mythological story-book character. This character presents the archetype.The mother archetype is symbolized by the primordial mother or earth mother of mythology, by Eve and Mary in western traditions, and by less personal symbols such as the church, the nation, a forest, or the ocean. agree to Jung, individual whose own mother failed to satisfy the demands of the archetype may well be one that spends his or her life seeking comfort in the church, or in identification with the motherland, or in meditating upon the figure of Mary, or in a life at sea. Mana You must understand that these archetypes are not rightfully biological things, like Freuds instincts.They are more spiritual demands. For example, if you dreamt about long things, Freud might suggest these things represent the phallus and ultim ately sex. But Jung might have a very different interpretation. Even dreaming kinda specifically about a penis might not have much to do with some unfulfilled need for sex. It is curious that in primitive societies, phallic symbols do not usually refer to sex at all. They usually symbolize mana, or spiritual power. These symbols would be display on occasions when the spirits are being called upon to increase the yield of corn, or fish, or to heal someone.The connection amongst the penis and strength, between semen and seed, between fertilization and fertility are understood by most cultures. The shadow Sex and the life instincts in cosmopolitan are, of course, represented somewhere in Jungs system. They are a part of an archetype called the shadow. It derives from our prehuman, animal past, when our concerns were limited to survival and reproduction, and when we werent self-conscious. It is the dark side of the ego, and the evil that we are undetermined of is often stored there. Actually, the shadow is amoral neither good nor bad, just like animals.An animal is capable of tender care for its young and vicious killing for food, but it doesnt discern to do either. It just does what it does. It is innocent. But from our human perspective, the animal world looks rather brutal, inhuman, so the shadow accommodates something of a garbage can for the parts of ourselves that we cant quite admit to. Symbols of the shadow include the snake (as in the garden of Eden), the dragon, monsters, and demons. It often guards the entrance to a cave or a pool of water, which is the collective unconscious. adjacent time you dream about wrestling with the devil, it may only be yourself you are wrestling with The persona The persona represents your public image. The boy is, obviously, related to the word person and personality, and comes from a Latin word for mask. So the persona is the mask you put on before you show yourself to the outside world. Although it begins as an ar chetype, by the time we are finished realizing it, it is the part of us most distant from the collective unconscious. At its best, it is just the good impression we all wish to present as we fill the roles society requires of us.But, of course, it can also be the false impression we use to manipulate peoples opinions and behaviors. And, at its worst, it can be mistaken, even by ourselves, for our original reputation Sometimes we believe we really are what we pretend to be Anima and animus A part of our persona is the role of male or womanly we must play. For most people that role is determined by their physical gender. But Jung, like Freud and Adler and others, felt that we are all really bisexual in nature. When we begin our lives as fetuses, we have undifferentiated sex organs that only gradually, under the influence of hormones, become male or female.Likewise, when we begin our social lives as infants, we are neither male nor female in the social sense. Almost immediately as soon as those pink or blue booties go on we come under the influence of society, which gradually molds us into men and women. In all societies, the expectations placed on men and women differ, usually establish on our different roles in reproduction, but often involving many details that are purely traditional. In our society today, we still have many remnants of these traditional expectations.Women are still expected to be more nurturant and less aggressive men are still expected to be strong and to ignore the emotional side of life. But Jung felt these expectations meant that we had developed only half of our potential. The anima is the female sight present in the collective unconscious of men, and the animus is the male aspect present in the collective unconscious of women. Together, they are referred to as syzygy. The anima may be personified as a young girl, very spontaneous and intuitive, or as a witch, or as the earth mother.It is likely to be associated with deep emotional ity and the pressure of life itself. The animus may be personified as a wise old man, a sorcerer, or often a number of males, and tends to be logical, often rationalistic, and even argumentative. The anima or animus is the archetype through which you report with the collective unconscious generally, and it is important to get into touch with it. It is also the archetype that is responsible for much of our love lifeWe are, as an ancient Greek myth suggests, always looking for our otherhalf, the half that the Gods took from us, in members of the opposite sex. When we fall in love at first sight, then we have found someone that fills our anima or animus archetype particularly well Other archetypes Jung said that there is no fixed number of archetypes that we could simply list and memorize. They overlap and easily melt into each other as needed, and their logic is not the usual kind. But here are some he mentions Besides mother, their are other family archetypes. Obviously, there is f ather, who is often symbolized by a guide or an authority figure.There is also the archetype family, which represents the idea of blood relationship and ties that run deeper than those based on conscious reasons. There is also the child, represented in mythology and art by children, infants most especially, as well as other small creatures. The deliveryman child celebrated at Christmas is a manifestation of the child archetype, and represents the future, becoming, rebirth, and salvation. Curiously, Christmas falls during the winter solstice, which in northern primitive cultures also represents the future and rebirth. People employ to light bonfires and perform ceremonies to encourage the suns return to them.The child archetype often blends with other archetypes to form the child-god, or the child-hero. Many archetypes are story characters. The hero is one of the main ones. He is the mana personality and the defeater of evil dragons. Basically, he represents the ego we do tend to identify with the hero of the story and is often engaged in chip the shadow, in the form of dragons and other monsters. The hero is, however, often dumb as a post. He is, after all, ignorant of the ways of the collective unconscious. Luke Skywalker, in the wind Wars films, is the perfect example of a hero.The hero is often out to rescue the maiden. She represents purity, innocence, and, in all likelihood, naivete. In the beginning of the Star Wars story, Princess Leia is the maiden. But, as the story progresses, she becomes the anima, discovering the powers of the force the collective unconscious and becoming an equal partner with Luke, who turns out to be her brother. The wise old man guides the hero. He is a form of the animus, and reveals to the hero the nature of the collective unconscious. In Star Wars, he is played by Obi Wan Kenobi and, later, Yoda.Notice that they teach Luke about the force and, as Luke matures, they die and become a part of him. You might be curious as to the archetype represented by Darth Vader, the dark father. He is the shadow and the master of the dark side of the force. He also turns out to be Luke and Leias father. When he dies, he becomes one of the wise old men. There is also an animal archetype, representing humanitys relationships with the animal world. The heros faithful knight would be an example. Snakes are often symbolic of the animal archetype, and are thought to be particularly wise.Animals, after all, are more in touch with their natures than we are. Perhaps loyal little robots and reliable old spaceships the Falcon are also symbols of animal. And there is the trickster, often represented by a clown or a magician. The tricksters role is to hamper the heros progress and to generally make trouble. In Norse mythology, many of the gods adventures originate in some trick or another played on their majesties by the half-god Loki. There are other archetypes that are a little more difficult to talk about. One is the o riginal man, represented in western religion by Adam.Another is the God archetype, representing our need to comprehend the universe, to give a meaning to all that happens, to see it all as having some purpose and direction. The hermaphrodite, both male and female, represents the union of opposites, an important idea in Jungs theory. In some religious art, Jesus is presented as a rather maidenly man. Likewise, in China, the character Kuan Yin began as a male saint (the bodhisattva Avalokiteshwara), but was portrayed in such a feminine manner that he is more often thought of as the female goddess of compassionThe most important archetype of all is the self. The self is the ultimate unity of the personality and is symbolized by the circle, the cross, and the mandala figures that Jung was hearty of painting. A mandala is a drawing that is used in meditation because it tends to draw your focus back to the center, and it can be as simple as a geometric figure or as complicated as a stai ned glass window. The personifications that best represent self are Christ and Buddha, twain people who many believe achieved perfection. But Jung felt that perfection of the personality is only truly achieved in death.

Lifestyle and Sustainability Essay Example for Free

Lifestyle and Sustainability EssayLifestyle and Sustainability are two different concepts combined together to describe how people should live nowadays. With the matters like the growth of modern technology, milieual degradation, and pollution, we now consider the best ways to live our lives without jeopardizing our environment and the future generations. Now, were concerned not only about alimentation in comfort and ease, but also about the sustainability of the world we live in, of our environment and our resources. Lifestyle is defined as a way of life, the manner by which a person lives. It involves various behaviors and practices regarding ones social relations, consumption, entertainment, and fashion. These behaviors and practices are composed of various habits, conventional modes of action, and reasoned actions. Simply put, lifestyle is ones style of living it is very personal and depends on the person who lives it. In relation to lifestyle, we come across the concept o f sustainability, which literally fashion to sustain or the ability to maintain certain processes or state. Nowadays, sustainability is often connected to how we human beings live.Concerns about the environment, pollution, and shortage of resources have driven us to apply sustainability in any aspect of our lives (Sustainability Reporting Program, 2004). We think of sustainable ways to build our homes, use our innate(p) resources, dress up, and grow our food. Somehow, we have connected sustainability with how we live, and it is now considered as a lifestyle. One important aspect of a sustainable lifestyle is food consumption, and in relation to that, we come across the concern of sustainable means of exploitation our foods.An important issue is brought up when we talk about sustainable means of growing food, and that is the use of pesticides. We are all familiar about pesticides, because it is the conventional means of eradicating the pests in our homes, properties, plants and c rops. However, the use of certain pesticides is deemed as un-sustainable because of the health risks they carry with them (EurActiv, 2008). It can also affect other organisms in the environment aside from the pests that they kill.To better guess pesticides, we need to know more about them, including the history, benefits, types, and other aspects as well. Pesticides have been utilize several thousand years ago, being utilized by earthly concern to protect their crops and plants from pests (Medline Plus, 2009). One of the first cognize pesticides used was sulfur dusting in Sumeria. In later centuries, mad used toxic chemicals like arsenic, mercury and rifle to kill pests. Natural pesticides were also used, like nicotine sulfate extracts from tobacco leaves, pyrethrum from chrysanthemums, and rotenone from the roots of tropical vegetables.These pesticides benefited man in several ways. The first, and possibly the most prevalent reason for pesticide use are for the protection of crops. Pesticides contain potent chemical ingredients which kill or deter insects and other pests that consume and destroy mans crops. Another application of pesticides is disease control, regulating or controlling the organisms which are considered harmful to health. A good example is the use of pesticides to kill mosquitoes which are known carriers of deadly diseases like dengue fever, west Nile virus, and malaria.Insecticides are also used in killing parasites like fleas and ticks in bigger animals like horses and cattle. It is also used to kill termites that can cause structural damage to our homes and dwellings. Overall, pesticides are used in variety of ways, all for the benefit of humans. We can classify pesticides into two study types, chemical or synthetically prepared pesticide, and biological or biochemical pesticide. We are more familiar with chemical pesticides because theyre the conventional pesticides. These are do from various chemical components, like the ones men tioned earlier.This type of pesticide is easier to produce because of the abundance of their chemical components, and is more potent and is more effective when it comes to killing the pests. The downside of this type however, is that it has harmful implications to the environment and to human health. The other type of pesticide is the biological or biochemical pesticide. This type is produced from plant extracts which can deter or kill insects. The biological pesticides use the natural enemies of certain plant pests. Other insects and spiders are used because they prey on these pests, regulating their population naturally.References EurActiv. (2008). Pesticides Tough negotiations ahead as MEPs back bans Retrieved April 14, 2009, from http//www. euractiv. com/en/sustainability/pesticides-tough-negotiations-ahead-meps-back-bans/article-176936 Medline Plus. (2009). Pesticides Retrieved April 4, 2009, from http//www. nlm. nih. gov/medlineplus/pesticides. hypertext mark-up language Sust ainability Reporting Program. (2004). Pollutants, Sustainability, Health, and Environment. Retrieved April 14, 2009, from http//www. sustreport. org/issues/health_env_pollut. html

Spoken language versus written language

Spoken delivery versus written languageSpoken vs. written languageNot so huge time ago, the written language played much bigger role in second language learners life than the spoken language. According to Brown (2000) immediately the importance of teaching the spoken language is universally acknowledged (p. 1). For example, many scientists state that people should learn speaking and auditory modality, as well as writting and indication furthermore, learners should spend more energy on listening. Thus generally one trick claim it is more difficult to learn how to understand the spoken language than the written.First of all, during listening, learners cannot focus on one section as they would do in a instructing task. Listeners do not have opportunity to read back, if they misunderstand an expression or forget the beginning of the text. Furthermore, according to Ridg focal point (2000) they do not have the possibility for looking a word up in the dictionary, or guessing the mea ning of a word from its context (p. 3.), like they do it in a teaching exercise.Secondly, during listening learners depend on the vogue of the text and on the listening environment more than in the case of reading. As Field (2000) points out, a listener, who has difficulties in identifying words in connected speech(p. 2.), can also have problems with different dialects, and the style and the speed of the text he or she listens to, because native speakers speak only clearly enough to make themselves silent in a particular context (Brown, 1990, p. 2.). Furthermore, listeners can be confused by the noisy, annoying environment, for example, during a conversation on the street or a crowded restaurant, while these conditions do not appear in a written text.Thirdly, during a listening exercise, the motivation of learners is always lower, because these kinds of tasks scare listeners, adding, that in reading they are braver, because of the advantages which are mentioned at the second para graph. So to become a good listener, the most important aim is to find the faith in ones big businessman to apply a listening readiness (Field, 2000, p. 1.), because after this momentous step, a text volition not cause so much fear. Furthermore, listeners should be open to determine the complexity of the given tasks, because then they can choose the appropriate level for themselves, so they will probably not fail and their self-confidence will improve. However, according to Ridgway (2000), grading texts is problematic (p. 3.), so it can be another serious controversy.Finally, practising listening is more difficult than reading. For instance, it is not easy to learn listening skills, because as Brown (1990) says, the students are not receiving any help in learning (p. 3.) ,but they have to realise alone how to set up the process of listening and improve their facilities. Moreover, learners abilities to listening are not similar to everyone, so the ways of practice should be differ ent from each other. For example, even in a class, which is hardly a(prenominal) in number, the teacher should prove at least four different ways of learning listening, but unfortunatelly it is not possible. It follows that learners have to find the best way independently.In conclusion, learning and listening to the spoken language is more difficult, than learning the written language, because listeners cannot focus on one section they are dependent on the style of the speech and the listening environment they are threatened, if they get a task at higher level and they need different ways to manage and more help from teachers. ReferencesBrown, G. (1990). Listening to spoken English. London, England Longman.Field, J. (2000). Not waving but drowning a reply to Tony Ridgway. ELT Journal Volume 54/2Ridgway, T. (2000). Listening strategies- I beg your pardon? ELT Journal Volume 54/2

Crohns Disease And Modulen IBD

Crohns Disease And Modulen IBDCrohns disease and Modulen IBDCrohns disease is a chronic disease associated with inflammations of the digestive tract. However, most often the cut down part of the intestine (the ileum) is affected. Crohns disease is characterized by periods of remission of sin and exacerbations. Currently, there is no remedy for Crohns disease inducing and maintaining remission of disease activity, addressing complications and correcting malnutrition ar the most preponderant objectives of treatment.Nestles Modulen IBD is especially composed for patients with Crohns disease. Modulen IBD is a casein-based formula that is rich in transforming proceeds factor-beta (TGF-B2). This nutritionally complete polymeric formula nates be given every by the nasogastric route or oral examinationly as the sole parentage of nutrition or as a supplement. According to Nestle, Modulen IBD is suitable for patients over cardinal years of age and can be reconstituted to a variety of caloric densities.Evaluation of Modulen IBD based on evidence in literatureBoth corticosteroids as enteral nutrition (EN) ar used in the treatment of Crohns disease. However, the impressiveness of EN compared to the use of conventional steroids is controversial. Both the effectiveness of exclusive EN therapy as basal therapy to induce remission in Crohns disease as well as the efficacy of EN for the maintenance of remission in Crohns disease are recently evaluated.In a Cochrane meta-analysis of six trails including 192 patients in the EN pigeonholing and 160 patients in the steroid group, it was concluded that EN can induce remission of fighting(a) Crohns disease. However, this effect was found to be low-level to steroids. These findings are in line with past meta-analyses. In contrary, it is indicated that the effectiveness of EN diverges between adults and children two paediatric trials (of which one was an abstract) with a total of 58 patients and a previous meta-analysis w ith 147 children demonstrated that EN equals the efficacy of steroids in the induction of remission in pediatric Crohns disease. Moreover, no dissimilarities in the effectiveness of elemental nutrition and non-elemental nutrition can be found based on 10 trials including 344 patients.A recent review of Akobeng and doubting Thomas (2007) showed that supplementary EN can be effective for maintenance of remission in Crohns disease. Data is based on two recent randomized clinical trials, however, sample sizes were too small to provide statistical power.RecommendationsIt is strongly indicated that steroids are to a greater extent effective in inducing remission in Crohns disease compared to EN. Additionally, obligingness might be less for exclusive nutritional intervention compared to the use of steroids several studies demonstrated a higher withdrawal rate in patients that were enured with EN compared to patients receiving steroids. Nonetheless, the use of steroids as a first line tre atment in children should be carefully considered for several reasons. First, it is shown that EN in children is equally effective as steroids in the induction of remission. Moreover, the use of steroids is often associated with side effects in children such as impaired growth and bone mineral tightness 1 3 the use of EN is regarded as safe. A long-term randomized pediatric trial of 37 patients demonstrated that withdrawal rates were comparable in the group of children receiving EN as well as in the group receiving steroid treatment withdrawal rates in the EN group were even inferior to those observed in adult studies. Accordingly, it is recommended to use EN to induce clinical remission in the growing child suffering from Crohns disease. Additionally, adults can be treat with EN as an alternative for conventional steroid use if they suffer from intolerances to steroids or if they (strongly) denote to prefer the use of EN above steroids. Since it is suggested that elemental and non -elemental diets are equally effective, it is advisable to treat patients with a polymeric diet such as Modulen IBD since polymeric diets have a higher palatability and compliance is evaluate to be improved.Although the current evidence suggests that supplementary EN may be effective for maintenance of remission in Crohns disease, evidence is not indisputable and it is indicated that more research is needed to confirm these findings. Furthermore, studies should be performed to elucidate the workaday amount of EN required to maintain clinical remission in Crohns disease patients as well as the cost-effectiveness of supplementation as the impact on the quality of life for the patient. Moreover, the compliance of supplementation is expected to be low since the end-point for patients is unclear. In conclusion, EN is advisable in children during a remission to avoid steroid side-effects such as an impaired growth and development. In special cases, Modulen IBD can be prescribe to adult s. For the time being, Modulen IBD supplementation for the maintenance of remission is not advised. The additional benefits for mucosal healing, growth, nutritional status and quality of life strengthens the argument for considering its use as primary therapy.Kosten, Compliance. polymeric nutrition is more palatable than elemental nutrition polymeric diets are less expensive and more palatable than elemental diets, and therefore it would bet reasonable to suggest that there is no place for the elemental diet. Improvement quality of life? Improvement nutritional status?Module ibd is a naturally complete powdered feed, designed to meet the specific nutritional needs of people with Crohns disease. It is free from gluten, lactose and is suitable for vegetarians.EN by means of a polymeric diet can be given via the nasogastric or per oral route. Module IBD is designed for patients with Crohns disease, can be used as the sole source iof nutrition or as an oral supplement.The specific pol ymeric diet selected was a highly palatable, casein-based formula rich in TGF-B2 (transforming growth factor) which can be taken by mouth.Crohns disease is a chronic inflammatory disease of the intestines. Crohns disease frequently occurs in the lower part of the small intestine (the ileum), however, it can affect any part of the digestive tract, from the mouth tot the anus. Crohns disease is a cgronic relapsing consition with a high morbidity. There is no cure for Crohns disease. intercession is aomed at inducing and maintaining remission of disease activity, correcting malnutrition, addressing complications, and thereby improving the quality of life of patients.The relative merits of corticosteroids and enteral nutrition in the treatment of Crohns disease body an area of controversy.There was a cumulative withdrawal rate of 26% in those receiving enteral nutrition compared to zero in the steroid group... there was a 39% withdrawal rate in the enteral group compared to only 9% in the steroid group.In the pediatric study, the majority took the feed orally, hardly if they failed adequate oral consumption, NG feeds were administered (in 23.5% of subjects). The withdrawal rates were similar in both the neteral nutrition (10.5%) as in the steroid arm (11.1%).The mild active subjects were allowed to take the feeds orally, while those with moderate to severe disease received the diet nasogastrically.Although polymeric diets are more palatable, failure can occur if inadequate oral administration occurs, and the nasogastric route should then be used to optimize compliance and effectiveness.Although exclusion of a normal diet/and or the nasogastric route of administration mey be viewed as barriers to enteral nutritional therapy, even young children can learn to insert the tube for overnight feeds. may suggest that the benefits of enteral nutrition discord between adults and children.Although the majority of data suggests that patients treated with corticosteroids m ore often achieve clinical remission, it is well established that corticosteroids fail to induce mucosal healing.Studies demonstrate a substantial higher drop-out rate for continuing enteral nutritional theraphy, whether given orally or by overnight nasogastric intubation.Enteral nutrition has important growth and developmental benefits and continues to be a recommended therapy for children with Crohns disease.The sample sizes of both included studies were small and the studies lacked statistical power. It is therefore difficult to draw any definite conclusions from these data. Future studies should be well-powered and should also investigate the amount of enteral nutritional supplements that will produce optimal benefits. These studies should also assess cost-effectiveness and the impact of supplementation on patientsquality of life.The optimal daily amount of enteral nutrition that needs to be consumed is unknown.In individual cases, EN can be provided to adults steroid intoleranc e, patient refusal of steroids or undernourished individuals. preaching can take 4-8 weeks, depending on the patients characteristics.

Case Summary Hypertension In Pregnancy Health And Social Care Essay

Case Summary Hypertension In Pregnancy Health And Social C ar EssayMdm. SM is a 30-year-old Malay female of large(predicate)a 5 parity 3+1 who is at 37 weeks and 5 brassreal days of motherhood. She was diagnosed to have hypertension in maternalism during antenatal bite fol upset-up in Klinik Kesihatan Simpang Renggam at 36 weeks and pre-eclampsia ( stock certificate embrace 160/100mmHg, water dipstick albumin 1+) 3 days in the beginning admission. She was admitted to infirmary Kluang and started on Tab. methyldopa 250mg TDS. She was advised for induction of drudge in view of preeclampsia at term and she requested to be transferred to hospital Batu Pahat (HBP). She did non have whatever(prenominal) signs and symptoms suggestive of surd preeclampsia or labour. During admission to HBP, tablet prostin 1.5mg was inserted into the posterior fornix twice to induce labour precisely there was no change in cervical os and symptoms of labour. Decision was made to try artifica l rupture of membranes. However, following the procedure, inseparable monitoring detected foetal distress and as unwritten delivery was non imminent, Mdm. SM was agreeable for tinge lower section caesarean section under general anaesthesia. A healthy infant boy was delivered (weight 2.9kg, Apgar score 91105) and there were no intra or post- shamus complications. Following the surgery, both m some other and infant were well in the ward. Mdm. SM was ambulating and tolerating orally and by the 2nd post-op day, both had passed urine and motion. contuse inspection on day 2 showed clean, non-gaping affront. As she was well, decision was made to discharge her and she was addicted appointment to review her blood blackjack and operative lesion at the postnatal clinic at KKSR. On discharge, her blood force per unit area was cxl/70mmHg (without medication) and urine dipstick albumin was trace. Analgesia given on discharge were mefenemic acid and paracetamol. educatee comprise capi tal of Minnesota Kong Fu-Xiang ID NO M0508129 score OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics gynecologyPATIENTS DETAILSI/C NUMBER 800318015794 AGE 30SEX womanly DATE OF ADMISSION 20/6/2010R/N 13585932) CLINICAL HISTORYChief ComplaintElevated blood pressure detected in maternity at 36 weeks of gestation. news report of Present IllnessMdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is soon at 37 weeks and 5 days of gestation. She was referred to hospital Kluang from Klinik Kesihatan Simpang Renggam (KKSR) for proud blood pressure detected on routine antenatal follow-up and ulteriorly transferred to Hospital Batu Pahat (HBP) for induction of labour in view of her development of high blood pressure in pregnancy. Her elevated blood pressure was start-off detected during her routine antenatal follow-up at Klinik Kesihatan Simpang Renggam 10 days before admission to HBP. During this visit, her blood pressure was recorded as 150/90mmHg and she alike complained of slight two-sided swelling of her feet but otherwise had no other complaints. The feet swelling resolved after 3 days. Throughout the next 7 days, she went to KKSR every alternate day for monitoring and 3 days before admission to HBP, her blood pressure was noted to be 160/100mmHg with presence of albumin 1+ on urine dipstick that was previously not present. She was immediately given tablet labetolol 100mg and admitted to Hospital Kluang where she was subsequently started on tablet methyldopa 250mg 8-hourly. Three days after admission to Hospital Kluang, she was advised by the doctor to undergo induction of labour and she thus requested to be transferred to HBP so her family members in Batu Pahat could take care of her. During the course of these events, she did not experience shortness of breath, judgementache, blurring of vision, epigastric pain, seizures, abdominal pain, vaginal bleeding, nausea, vomiting, palpitations, or recurrence of the foot swelling. At time o f admission, she did not experience contraction pain, show, leaking of liquor. Fetal movements were good.systemic ReviewMdm. SM did not have fever. Her appetite was good and her urinary and bowel habits were normal. Her sleep was unaffected.Antenatal HistoryThis was an unplanned but wanted pregnancy. Mdm. SM realized she was pregnant when she missed her period, of which the last was 28/12/09. She bought a pregnancy test kit and it tested positive. She subsequently did her booking at KKSR at 7 weeks of period of amenorrhoea. At booking, her blood pressure was 120/80mmHg, hemoglobin 13.4g/dL, sugar undetected, and urine albumin negative. Infective screening was negative and blood fount O positive. Her expected due date was given as 14/8/10. During follow-up 1 month previous(a)r, she had her first ultrasound scan which run aground her uterus to be larger than dates. Her due date was revised to 6/7/10. Modified glucose tolerance test d one and only(a) twice during pregnancy were nega tive. She go through morning sickness and vomiting during the first 3 months of pregnancy but it was not implike and she could cope without medication. Throughout the pregnancy, she was diagnosed to have urinary tract transmittal twice and was treated with antibiotics. A further 3 ultrasound scans were done and all were normal. She was also compliant to the supplements given throughout pregnancy. thither were no other problems during the antenatal follow-up until the detection of elevated blood pressure 10 days before admission to HBP.Past Obstetric HistoryThis is her fifth pregnancy and her last childbirth was in 2008. She has 3 children, 2 boys and a girl, of whom all were born via vaginal delivery at postdate after induction of labour. give birth weights ranged from 2.7 to 3.0kg, all are healthy with no complications and were breastfed. However, during her 3rd pregnancy, she suffered a miscarri jump on during the 12th week and dilatation and curettage was performed during tha t admission.Gynae Menstrual HistoryMdm. SM achieved menarche at the age of 12. Her menstrual cycles have always been regular with 28 days per cycle and 5 to 7 days of flow. She does not experience menorrhagia or dysmenorrhoea. She has never had a cervical smear done and has never used oral contraceptive pills. She has not required medical exam attention for any gynecologic problem.Past checkup HistoryMdm. SM has never been diagnosed with any chronic disease such as diabetes, hypertension, and asthma before. She has also never been admitted for non-pregnancy related reasons. She also does not have any known food or drug allergies.Family HistoryMdm. SM is the eldest of three siblings. Her youngest sister also had gestational hypertension. Her preceptor has hypertension and her mother had diabetes, but passed away 2 years ago due to tuberculosis. All family members have been screened and all tested negative for tuberculosis.Social HistoryMdm. SM is now a housewife. She formerly wor ked in a factory but decided against returning to work following her last pregnancy in 2008 for her childrens benefit. She is a non-smoker and does not consume alcohol. Her husband is a short-haul lorry driver and smokes, but tho outside their home. They live somewhat off Kluang, and it takes them slightly everyplace an hour to reach HBP, and 15 minutes to reach KKSR.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology3) FINDINGS ON CLINICAL EXAMINATION(Mdm. SM was examined by me on the 2nd day of admission)Mdm. SM was alert, conscious and cooperative. She was not in any pain or distress. She was sit down comfortably on her bed. On examination, there was no pallor, jaundice or pedal edema. Her reflexes were not b pretend. Her clinical parameters areBlood Pressure 124/80 mmHg heart and soul Rate 95 beats per minute. Regular rhythmRespiratory Rate 20 breaths per minuteTemperature 37CExamination of the cardiovasc ular system, respiratory system, fundus, thyroid and breasts were normal.On examination of the abdomen, it was distended with gravid uterus as evidenced by linea nigra, and striae albicans. There was no striae gravidarum, scars, or pulsations noted. On palpations, the abdomen was soft and non-tender, uterus non-irritable, and fetal parts felt. The symphysio-fundal height was 36cm, which corresponds to dates. On examination, this is a singleton fetus at longitudinal lie with cephalic presentation, with the fetal back on the maternal left. The fetal head was four fifths palpable. Estimated fetal weight is 2.8 to 3.0kg. Liquor is adequate. Fetal heart was heard and the rate was 142 beats per minute.Vaginal examination (by medical officer on admission) revealed no perineal, vulval or vaginal abnormalities. Cervical os was 1 cm with cervix tubular, soft and axial, station high and membrane intact. Bishops score was 3/10.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr . Sharifah Sulaiha ROTATION Obstetrics Gynaecology4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONINGProvisional DiagnosisPreeclampsia in pregnancyMdm. SM developed new onset elevated blood pressure of 160/100mmHg at 36 weeks of gestation and urine dipstick albumin of 1+ (300mg/L). This fits the minimum requirement of preeclampsia among the hypertensive diseases in pregnancy. However, Mdm. SM did not experience any symptoms to suggest a severe preeclampsia or be eclampsia such as headache, visual disturbances, epigastric pain, vomiting, liver tenderness. The urine dipstick for albumin is not the best way to detect proteinuria required for the diagnosis of preeclampsia 3 and is usually only used for screening, but as the blood pressure and urine albumin were persistently elevated, it is better to err on the side of caution and treat Mdm. SM as such since unhurrieds with relatively mild preeclampsia can rapidly further into severe disease 1. Following the perennial positive detection of urine albumin of only 1+, more definitive tests should be performed to better quantify her proteinuria 2,3.Differential DiagnosisPregnancy-induced hypertension, late onsetAs Mdm. SM has been compliant to her antenatal follow-ups and did not have elevated blood pressure detected at any time before 36 weeks of gestation, it is likely that she has developed the onset of a hypertensive disease in pregnancy and it appears to be of late onset as it developed only after 32 weeks gestation. However, as subsequent visits showed urine dipstick albumin of 1+, indicating the onset of proteinuria (although poor predictive value and not as evidential as 2+) 3, it might prove wiser to be more vigilant and assume that Mdm. SM does indeed have preeclampsia as it would be anserine to dismiss these warning features despite the fact that she does not demonstrate any suggestive symptoms because it is possible that even patients with no prodromal signs may suddenly progress into eclampsia 1,3.Essential hypertension in pregnancy with superimposed preeclampsiaAnother possibility that we may entertain is that Mdm. SM has had previously undiagnosed essential hypertension with currently superimposed preeclampsia. However, this seems quite an unlikely. Firstly, Mdm. SM is young at the age of 30 and unlikely to suffer from essential hypertension as this disease viridity presents after the age of 40. Secondly, at no time throughout antenatal follow-up did she have elevated blood pressure recorded before that bad-tempered visit at 36 weeks of gestation. However, following delivery of her infant, she should have her blood pressure re suppressed during postnatal follow-up care at 6 to 12 weeks post-delivery. If her blood pressure if still elevated at that time, then it will be more likely that she has essential hypertension.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology5) IDENTIFY AND PRIORITISE THE PRO BLEMS1. Elevated blood pressure and its implications in pregnancyMdm. SM has newly discovered elevated blood pressure at 36 weeks of gestation. This is considered late onset but is not uncommon, and gives rise to a spectrum of hypertensive disorders in pregnancy. While it seems that at first she has gestational hypertension, the mildest of the disease spectrum, she demonstrated proteinuria on her subsequent antenatal visit, therefore concluding that she has preeclampsia. Hypertensive disorders in pregnancy have the potential to roll both mother and infant at amplifyd stake of mortality. Its complications are elaborated below. During admission, Mdm. SM should be monitored for any change in her condition as she may quickly progress into severe disease states and this would require urgent intervention, the most definitive being the delivery of the infant. Ward management includes close note of both mother and infant, and medication to control the elevated blood pressure.2. facilit y of labour in view of preeclampsia at termTermination of the pregnancy is the only definitive sure for preeclampsia. On presentation, Mdm. SM has features categorized as mild preeclampsia. Normally, severe preeclampsia would dictate the need for antihypertensive and anticonvulsive therapy followed by subsequent delivery and symptoms such as headache, epigastric pain, and visual disturbances may indicate this. The fetal age is usually an important deciding factor when it comes to inducing labour as the treatment goals seek the best outcome for both mother and infant. As Mdm. SM is already at term and there have been no issues previously detected regarding the health of her fetus, it should be safe to proceed with induction of labour. There is also no reason to prolong the pregnancy as the assay of eclampsia increases. If for any reason an obstetric reason arises e.g. fetal distress, delivery should proceed via caesaren section.3. Impending eclampsia and other potential complication sWarning signs and symptoms of impending eclampsia or severe preeclampsia include headache, visual disturbances, epigastric pain, reduced urine output, edema and ultimately, convulsions. These symptoms should be recognized early so the necessary intervention can take place. Seizures increase the risk of maternal and perinatal morbidity and mortality rates. Some maternal complications are placenta abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, and acute nephritic failure. different major complications that may occur as a result of severe preeclampsia are HELLP syndrome, pulmonary embolism and stroke. Fetal complications include growth restriction, fetal distress, and death.4. Risk of post-partum eclampsiaIt is possible for eclampsia to occur in the postnatal period especially when the patient has reached term. In such cases, up to 44% of eclampsia occurs postpartum 3. As the risk is quite high, Mdm. SM should continue to be monitor ed in the ward for the development of any signs and symptoms. As she is comfortable and relatively symptom free while in the ward, it appears unlikely that she may worsen into an eclamptic state but the risk should not be afforded. As there are no guidelines to suggest an optimum postpartum inward observation period, it would depend on her clinical situation during the subsequent days following her delivery.5. Hypertension in pregnancy and its long term implicationsAs Mdm. SM has developed preeclampsia during this pregnancy, she is at increased risk to develop hypertensive or metabolic complications in future pregnancies. The risk of recurrence is in the main higher in earlier onset preeclampsia. At the same time, she should be evaluated in the postpartum period for the possibility of essential hypertension at the 6 week postnatal review. Also, women with preeclampsia are at an increased risk for developing hypertension, diabetes, hyperlipidemia, chronic renal disease, stroke and i schemic heart disease. Mdm. SM should be made aware of all these implications and should be educated on how she can prevent these via the modification of her lifestyle. She should also be advised to attend preconceptual counseling in the event of a future pregnancy and to come early for booking.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS1. water supply Dipstick for AlbuminTo look for the presence of albumin in the urine firstly, to confirm proteinuria, and secondly, to evaluate the severity of the preeclampsia. Urine dipstick for albumin should be repeated daily in the ward. Also, if in doubt, further investigation to quantify proteinuria can be done e.g. urine protein/creatinine fleck test 2,3.Results Urine dipstick albumin on admission was trace. Results at KKSR showed 1+.Interpretation This res ult could be due to the fact that the blood pressure has displace as Mdm. SM has been started on methyldopa and her blood pressure is under control. This does not mean that she no longer has preeclampsia. She should be checked daily for any changes in both blood pressure and proteinuria.2. Full Blood CountTo look for anemia which may require correction, haemoconcentration which may indicate severe preeclampsia 1, and platelet levels as HELLP syndrome is a complication that may arise in preeclampsia. This may also serve as baseline in case operative procedures are required.Result TWBC 12.0 x109/L (neutrophils 8.20, lymphocytes 2.70)Hemoglobin 10.7 g/dL Hematocrit 32.3% Platelets 354 x 109/LInterpretation The total white cell count is slightly raised, but this is to be expected in pregnancy. The hemoglobin is slightly low but this is also expected in pregnancy and should be monitored especially if the patient requires surgery or experiences anemic symptoms. There is no haemoco ncentration and the platelets are normal.3. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT)To obtain a baseline of the clotting profile in case operative procedures are required and also to look for potential coagulopathy as it is a possible complication of preeclampsia.Result PT 12.3s INR 1.05 APTT 39.6sInterpretation PT/INR/APTT is within normal range. Coagulopathy appears unlikely in Mdm. SM given that her platelets are also normal and her preeclampsia is not severe.4. Renal visibilityTo assess renal functions to look for elevation of creatinine as that would indicate severe preeclampsia and also to detect acute renal failure which is associated with increased risk of HELLP syndrome, placenta abruption and postpartum hemorrhage 1.Result Urea 1.3mmol/L Sodium 140mmol/LPotassium 3.7mmol/L Creatinine 51mol/LInterpretation Mdm. SM renal profile is normal and creatinine is not elevated, adding to the indicators that her preeclampsia is of the mild ca tegory. Low urea levels and good urine output also rules out acute renal failure.5. liver-colored Functions TestTo assess liver functions and its components such as liver enzymes and bilirubin which would be raised in severe preeclampsia or HELLP syndrome in which there is hemolytic anemia and elevated liver enzymes.Result Total protein 73g/L Albumin 33g/L Globulin 40g/LTotal bilirubin 0.5mg/ml reign bilirubin 0.2mg/ml Indirect bilirubin 0.3mg/mlALP 121U/L ALT 7 U/L GGT 7 U/LInterpretation Liver enzymes (ALT) and bilirubin levels are not elevated, indicating a mild preeclampsia and no biochemical evidence of HELLP syndrome. The ALP is slightly elevated, but this could be due to compression of the gravid uterus on the hepatobiliary tree.6. Serum Uric AcidElevated serum uric acid is an early biochemical sign of preeclampsia 1 and may help to predict maternal complications in preeclampsia 4.Results Serum uric acid 103mol/L Interpretation Serum uric acid levels are not eleva ted and are in fact, slightly lowered. This result indicates low likelihood of severe preeclampsia or maternal complications.7. Serum Lactate DehydrogenaseTo check for elevated levels which should indicate hemolytic anemia, a component of HELLP syndrome.Results Not done during this admission.8. Cardiotocograph (CTG)Done on admission as a baseline for fetal monitoring.Results service line fetal heart rate was 130 beats per minute, baseline variability was 5 10, accelerations present with no decelerations.Interpretation CTG is excited with no signs of any fetal compromise. CTG should be repeated following each procedure e.g. prostin insertion, AROM or if fetal compromise is suspected.9. Transabdominal UltrasonographyThis should be done to confirm fetal age, as hinderance of fetal age is important when it comes to deciding whether or not to induce labour in preeclampsia. Also to check for fetal well-being and growth restriction, but these requires repeated scans and plotting of grow th chart over a period of time.Result No ultrasonography was done during this admission. The last scan was done in Hospital Kluang before patient was transferred to HBP. The last scan reports fetal age corresponding to dates, AFI of 9, and no abnormalities detected with no mention of other findings.Interpretaion As fetal age is corresponding to dates and there is no suggestion of fetal compromise or restriction, it is safe to proceed with induction of labour.10. Urinalysis (UFEME)To check the levels of proteinuria which may be more quantitative than urine dipstick.Results Leukocytes, nitrite, protein, glucose, ketone, urobilinogen, and bilirubin were not detected.Interpretation No proteinuria was detected. This could mean that the patient does not have preeclampsia but rather gestational hypertension, or it could be undetected as the blood pressure has also become well controlled with medication. However, no risks should be taken and Mdm. SM should be closely observed in the ward. Either way, induction of labour and delivery would still be ideal for her as she has already reached term.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSIONWorking DiagnosisInduction of labour at term in view of mild preeclampsia in pregnancyComment As Mdm. SM has elevated blood pressure and urine dipstick albumin 1+ but has no physical or biochemical features suggestive of severe preeclampsia, the working diagnosis is mild preeclampsia. However, she should be monitored closely in the ward for any symptoms indicative of disease development. As she has reach term, it would also be wise to induce labour in her, especially given her history of postdates as delivery would be the only definitive management in such cases.Plan of management on admissionContinue T. Methyldopa 250mg 8-hourlyDaily urine albumin dipstickVital signs monitoring 4-hourlyBaseline cardiotocog raph on admissionFetal kick charting andLabour progress chartingTo notify immediately if spontaneous rupture of membranesTo notify immediately if strong contractions commenceEncourage orallyFor induction of labour with T. Prostin 1.5mg as Bishops score unfavourableTo notify immediately if any symptoms occurSTUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, reposition OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)Throughout the first two days of admission, Mdm. SM was comfortable in the ward with no development of any symptoms of severe preeclampsia, eclampsia, or labour. Her vital signs were stable with blood pressure ranging 122-138/70-84. On the morning of the 2nd day, tablet prostin 1.5mg was inserted into her posterior fornix under aseptic technique. Cardiotocograph was reactive and vaginal examination 6 hours post-insertion showed cervical os 3cm, cervix 2cm, soft and axial, and high station. Therefore, a 2nd tablet of prostin was inserted on the morning of the 3rd day. Once again, post-insertion cardiotocograph was reactive and vaginal examination 6 hours later showed no changes to before. Mdm. SM still did not experience any signs and symptoms of labour. She also did not have any symptoms indicating progression of her preeclampsia. On the morning of the 4th day, it was decided that Mdm. SM should undergo artifical rupture of membranes (AROM) rather than have a 3rd prostin tablet inserted. Cardiotocograph monitoring had been difficult so decision was made to insert fetal scalp electrode at the same time for internal monitoring. Following the AROM, internal monitoring revealed a drop of fetal heart rate from 130 to 100 beats per minute with no accelerations. Cervical os was still 3cm with no symptoms of labour. Decision was made to proceed with emergency lower section caesarean section (ELSCS) under general anaesthesia and Mdm. SM gave h er consent. Via ELSCS, a healthy baby boy was delivered weighing 2.9kg with Apgar score of 91105. There were no intra or post-operative complications. Post-operative medications given include IV ampicillin 500mg QID, subcutaneous heparin 5000 units BD, IV pitocin 40 units QID, IM pethidine 50mg PRN, Tab. paracetamol 1g QID and Tab. Mefenemic acid 500mg TDS. Throughout the next 2 days, Mdm. SM was comfortable in the ward and had mild operative site pain with no other symptoms and vital signs were stable. All medications except analgesia were stopped. She was ambulating well, tolerating orally and had passed urine and motion by the 5th day. As for the baby, breastfeeding had commenced and he had also passed urine and motion. The uterus was well contracted at 22 weeks size and dressing was not soaked. Inspection of the wound on the 6th day revealed a clean and non-gaping wound. She was counseled on contraception and indicated a gustatory modality for intrauterine contraceptive device. As she was well, she was fired with appointment to return to postnatal clinic at KKSR to review her blood pressure and operative wound in 1 weeks time. On discharge, her blood pressure was 140/70mmHg and urine dipstick albumin was trace.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology9) DISCHARGE PLAN, COUNSELLING AND MOCK prescription drugDischarge PlanTab. Mefenemic acid 500mg TDS PRNTab. Paracetamol 1g QID PRNFollow-up appointment at Klinik Kesihatan Simpang Renggam (KKSR) Postnatal clinic in 1 week to review blood pressure and operative wound.Follow-up appointment at KKSR in 6 weeks for review, cervical smear, and contraception.Counseling conscious to return immediately to the hospital if Mdm. SM has problems with the caesarean wound e.g. pain, discharge or if she develops any new or worrying symptoms. talk over on the need to be compliant to postnatal follow-up to review Mdm. SMs condition.Advised for cervi cal smear during postnatal follow-up as previously never done.Counseling regarding breastfeeding and contraception.Explain about the nature of pregnancy-related hypertensive disorders and its long term implications.Advised to attend antenatal clinic for preconceptual counseling if future pregnancy is desired, or to come for booking immediately once discovered to be pregnant.Advised to observe a healthy lifestyle in order to prevent development of conditions such as hypertension and diabetes.Mock PrescriptionTab. Paracetamol 1g QID PRN x 1/52Tab. Mefenemic acid 500mg TDS x 1/52STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology10) REFERRAL LETTER (IF APPLICABLE)Medical Officer,Postnatal Clinic,Klinik Kesihatan Simpang Renggam,86200, Simpang Renggam. 20th June 2010Mdm. SM (IC.800318015794)Date of admission 20th June 2010, Date of discharge 25th June 2010Problem Late onset hypertensive disease in pregnancyDear medical o fficer,Mdm. SM is a 30-year-old Malay lady of parity 4+1 who was diagnosed to have preeclampsia at 36 weeks of gestation during routine antenatal follow-up at your centre. During admission to our ward, she underwent induction of labour with tablet prostin and artificial rupture of membranes. However, fetal distress developed, picked up on internal monitoring and Mdm. SM underwent emergency lower section caesarean section under general anaesthesia. She delivered a healthy baby boy (2.9kg, Apgar 91105) with no complications intra- and post-operatively. We are discharging her into your care. Please review her blood pressure as scheduled and also offer contraception and cervical smear as previously never done. She has indicated preference for intrauterine contraceptive device. Do not hesitate to contact us immediately should the need arise. Thank you very much for your attention.Yours sincerely,Paul Kong Fu-Xiang (Final year medical student, IMU),Department of Obstetrics Gynaecology, H ospital Batu Pahat.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology11) LEARNING ISSUES IN THE 8 IMU OUTCOMES1. Disease prevention and health promotionHypertensive disorders in pregnancy are one of the most common antenatal problems and eclampsia is a major ancestry of maternal mortality. What are the ways in which some element of prevention can be instituted or to decrease the severity of preeclampsia?There harbour been certain strategies touted to prevent or modify the severity of preeclampsia. These are categorized as dietary supplements, antihypertensive medications, antioxidants, and antithrombotic agents 5. As low salt diet is one of the recommended dietary changes for hypertensive patients, De Snoo et al 1 was one of the earliest researchers to study the effects of low salt diet in preventing preeclampsia but this recital was discarded as it yielded no significant change. Knuist et al performed a randomiz ed controlled trial in 1998 and they reported that despite helping control blood pressure in non-pregnant individuals, a sodium-restricted diet was ineffective in 361 women in terms of prevention of preeclampsia 6. The dietary supplementation of calcium of at least 1 gram per day is recommended as class I-A evidence 2. Several studies showed that women with low calcium diets were at significantly increased risk of gestational hypertension 7,8,9. Levine et al performed a large, randomized-controlled trial and they found that there was no significant difference in outcome with calcium supplements versus placebos 10. This suggests that unless a pregnant woman has a low calcium intake, calcium supplements may have no added benefit 5. With regards to fish oil supplements and its cardioprotective fatty a

Endothelin Essay -- Health

Cardiovascular disease is one of the leading deaths in the United States. Pulmonary hypertension disease one type of cardiovascular disease that is due to the narrowing of the arteries within the lungs. When the arteries be narrowed the right side of the shopping center is unable to fondness blood through the lungs, pressure begin to build up and not enough oxygen is being picked up, therefore causing pulmonary hypertension. If there are damages to the endothelium, it can pay back this disease because it can produce more(prenominal) endothelin-1, which is one of the isomer of Endothelin that influence as a vasoconstrictor.IntroductionIt is important to have discussion available to patients who suffer from cardiovascular diseases. Since it is one of the leading causes of deaths in the United States, improving treatments will save many lives. Although heart disease occur more in adult patients, there are possible chances in which infants are affected by a disease known as the con genital heart disease. In order to have treatment for patient with heart disease, we need to look at the molecular level. Patients were examined and documents showed that endothelial injury may be the cause for pulmonary hypertension and other vascular diseases.PresentationEndothelin is a 21 amino acid polypeptide that has 3 different isoforms which are endothelin-1(ET-1), endothelin-2 (ET-2), and endothelin-3 (ET-3). ET-1 is located mainly in the endothelial cell but is a regulator of smooth muscle, heart, and kidney. ET-2 differs from ET-1 by 2 amino acids and is also found in the heart and kidney. ET-3 differs from ET-1 by 6 amino acids and is produced in the central nervous system like ET-1and in gastrointestinal (1). With researches, ET-1 is more focused on in cardiovascu... ...With different experimental selective information on animals and documents of patient with cardiovascular diseases, there no exact conclusion made on which receptors antagonist may cure the disease. Tri als are needed to teach whether ETA/B blockage or just ETA blockade is better in the treatment of hypertension or any other vascular disease. Although both decrease vasoconstriction, potential anti-endothelin therapy is available to patients.Works Cited1. Agapotiv, Alexei & Haynes, William. Role of Endothelin in Cardiovascular Disease. Journal of Renin0Angiotensin-Aldosterone System, 3.1 (2002) 2-10. .2. Bohm, Felix & Pernow, John. The importance of endothelin-1 for vascular dysfunction in cardiovascular disease. Cardiovascular Research, 76.1 (2007) 8-18..

Prejudice in Steinbecks Of Mice and Men Essay examples -- essays rese

Prejudice is a great time saver. You can form opinions without having to get the facts. This quote, once said by E. B. White, excellently states what the novel, Of Mice and Men, is exhausting to clearly state. Of Mice and Men is a profound novel that has many things to teach society. This novel, written by John Steinbeck, reflects many flaws in the world today. It mirrors many of the characteristics that both human possesses. Prejudice is still a common way of thinking in todays society, and to the people who feel victimized, it can be warm to overcome. Curleys married woman, Lennie, and Crooks all deal with outrage against themselves various ways.Curleys wife is what we in modern day might call a tease, exclusively there is more to her than just looks. The ranch workers do say thinks worry, well, I think Curleys married a tart, (28). Curleys wife, who never is engendern a name, is criticized before she has spoken one word. She is considered promiscuous right off the bat. Alt hough, she is not, the workers on the ranch tend to think that she is attempting to flirt with them. They claim that She got the eye I seen her give Slim the eye. Curleys wife only acts this way because she trying to fix the void between her and Curley with soul else. Part of the distance between Curleys wife and Curley is that his wife does not care for him the way he cares for her. She claims that she wasnt gonna stay no place where she couldnt get nowhere or make something of herself, so she married Curley, (88). When she says this, she implies that she settled for Curley when she could have been a huge star. She walks around the ranch telling people Im to find Curley, Slim. Well you aint tryin very hard. I seen him goin in your house... ...omin in, you might just as well, (74). While earlier on in Crooks life he wasnt always secluded from the white folks. He says The white kids play at our place, sometimes I went to play with them My ol man didnt like that. I never understood why, until now, (70). By saying this, Crooks expresses that he has so much pent up anger from people ridiculing his race. Crooks has almost accepted prejudice as a way of life. Prejudice is a common factor in society today. It is an excuse for people not to get to know someone because they do not feel it is necessary. Of Mice and Men portrays many flaws in society then and now. All three of these characters experience different forms of prejudice and deal with it different ways. In the end, they are secluded from gatherings of ranch workers. This book also brings the timeless phrase dont judge a book by its cover.