Sally Soprano Essay Example | Topics and Well Written Essays - 1500 words - 1

Sally Soprano - Essay Example Therefore, for the last two years, Sally was paid $25,000 for the last two years and $12,500 the last time she was paid. This indicates that Lyrics paid $12,500 per year. This reflects an inflation of 25%. Based on the last payment by Lyrics and the inflation rate, Sally must have been willing to sing for 150% Ãâ€" $12,500. This is the amount that Sally was paid most recently. Therefore, Sally said she would be willing to sing for $18,750. The author also provides a memo that indicates various issues that are to be considered in the agreement between Lyric and Sally Soprano. In the publicity section, the author poses two questions: what will lyric do? What will Sally do? According to the description of terms in the agreement, there are various sets of boundaries laid for the roles of both Lyric and Sally in terms of publicity. First, the two have specific parts to play in advertising for the sake of the company’s publicity. Lyric is to contribute a given amount of money to cater for advertising budgets. Lyric also agrees to increase the advertising budget by a given percentage while Sally agrees to contribute a dollar for every three dollars contributed by Lyric to cater for the increase in the advertising budget. However, this is subject to a given maximum dollars contribution by Sally. The ad Campaign will be given an input by Sally and her agent. In preparation for a meeting with Sally for a negotiation of terms of contract in this involvement, I will consider various aspects of negotiation that will enable me to strike a good deal for the interest of both Sally and Lyric. In this case, the context of negotiation in the agreement will be important. While it is necessary to maintain confidentiality in the negotiation between Lyric and Sally, it is also important to give a good image of a strong relationship between the two parties so that the public may appreciate

Legal advice to BGE Assignment Example | Topics and Well Written Essays - 1000 words

Legal advice to BGE - Assignment Example In its bid to raise capital in 1818, the company was enlisted in the public stock market. The company transformed into a corporation in 1906, and its mission is to achieve customer satisfaction by providing high quality energy services and products. From 1960 to 1980, the company experienced numerous growths and the climax was in 1967 when it built the first nuclear generating plant in Baltimore. In 1983, due to losses in its business operations, BGE sought diversification of its business initiatives but was rejected by the Maryland council since local laws did not allow such ventures (Dubinsky and Morgenstern, 1982). In 1989, the company’s nuclear power plant was shut down and it faced numerous fines deteriorating its financial capabilities. In 1992, with the passing of the Energy Federal Act, which allowed competition in the wholesale power market by retention of retail business, the company was able to reinvent itself (Williams, 1984). It responded by looking for a strategi c partner for the purposes of improving its profits. In 1995, the company formed a joint venture with Potomac Electric Power Company, and they engaged in reduction of staff and job overlapping. This was aimed at saving approximately a billion dollars. The merger was called off in December 1997 due to disagreements on cost sharing and regulatory laws of the District of Columbia (Moscardini & Betacourt, 1990). In 1998, the company made organizational changes and split its management into three distinct parts, namely unregulated subsidiaries department, utility operations department and power generation department. Currently, BGE has undertaken to improve the productivity of its services by rolling out the smart grid initiative. The smart grid initiative will allow clients to regulate their energy use with the money they are willing to spend and starting this year, the company will install two million smart meters and its devices in Maryland. After the installation, the company plans t o establish an online device that will enable customers to view their energy usage patterns and costs. The tool will give tips on effective consumption of energy, and outline a comparison on the neighbor’s energy usage pattern. This is called the green button technology. Clients will be able to view and download information of a similar manner concerning customers of other energy companies (Carvallo & Cooper, 2011). In rolling out this service, laws regulating the administration of the initiative must be put into consideration. At the federal level, the administrative law relevant to this initiative is the American Recovery and Reinvestment Act of 2009. In initiating the smart grid technique, BGE will face numerous costs, and ways and measures of reducing risks associated with implementation of this act needs to be looked at. The American Recovery and Reinvestment Act is an example of an administrative law that the company can invoke to minimize the risks associated with the initiative (Keyhani, 2011). The law allows compensation by the federal government to American companies suffering losses due to initiating policies meant to benefit its citizens. In Maryland, the most relevant aspects of administrative laws is the EmPOWER Maryland Efficiency Energy Act which regulates energy consumption and peak demands. It is the duty of energy companies in Maryland

Case Summary On The Effects Of Unstable Angina Nursing Essay

Case Summary On The Effects Of Unstable Angina Nursing Essay Mr AR is a 41 years old male. His calculated BMI was 20.9kg/m2. His presenting complaint was chest pain which has lasted for three days before being admitted into the hospital. His chest pain was of pressing type, it occurred even at rest and lasted for 5-10 minutes each time. It was relieved slightly by rest and it was always accompanied by numbness on his left hand. He had shortness of breath, orthopnea, headache and low effort tolerance. He complained of abdominal discomfort also. He had stopped taking all his medications for the past three days. He had a pacemaker fixed 16 years ago for his atrial fibrillation (AF), but the pacemaker stopped functioning 3 years ago. Due to financial constraint, he did not go for a new pacemaker replacement. He underwent an angiogram last year and was found that he has 2 blocked vessels. He has a history of hypertension too. Before being admitted into the hospital, he has been taking frusemide 40mg twice daily, hydrochlorothiazide 25mg once daily, perindopril 8mg once a day and amlodipine 10mg once a day for his hypertension. For his AF, he has been taking warfarin 5mg once daily and digoxin 125microgram once daily. In addition, he took simvastatin 40mg at night for the prevention of cardiovascular events. Mr AR was found to have poor compliance. He always missed the dose, took the medications at the wrong time and was unsure the reason behind taking all his medications. He was first admitted to the acute and emergency department. ECG was carried out and there was no ST-elevation. His blood pressure was found to be high, 172/126mmHg. No troponin test was done on Mr AR, the only available test results on cardiac enzymes were that of creatine kinase (CK), aspartate amino transferase (AST) and lactate dehydrogenase (LDH). All three were not elevated. Hence, he was diagnosed with unstable angina, gastritis and hypertensive urgency. He was given nifedipine 10mg, aspirin 300mg, Sublingual GTN and plavix 300mg in the acute and emergency department. His management plans were to monitor his vital signs every hourly for two hours followed by every two hourly and to carry out dextrostix test three times daily. He was given 60mg enoxaparin subcutaneously immediately and twice daily thereafter, intravenous ranitidine 50mg three times daily, sublingual glyceryl trinitrate (GTN) one tablet when required and IV frusemide 20mg twice daily. He was restricted to fliud intake of 800mL per day and started on fliud input and output monitoring. He will also be started on low salt diet for the management of his hypertension. On day 2, he no longer complained of chest pain. His potassium level was found to be slightly lower than normal range (3.3mmol/L). His BP was still high throughout the day, fluctuating at around 150/120mmHg. He was started on tablet clopidogrel 75mg once daily. On day 3, IV frusemide was changed to oral frusemide. On day 4 his blood pressure has already dropped to around 120/90 mmHg. He was planned for discharge and enoxaparin was to be stopped on that day. Disease overview and pharmacological basis of drug therapy Mr AR was diagnosed with 3 diseases. Only unstable angina will be discussed. Unstable angina (UA) is categorized under acute coronary syndrome (ACS) which is very common in the UK. According to the hospital episode statistic year 2002-2003, there were 83842 cases of UA in England and 4421 cases in Wales.1 UA happened when there is insufficient myocardial oxygen supply to meet the oxygen demand of the heart. The reduction in the oxygen supply is due to the disruption of artherosclerotic plaque, causing the formation of intracoronary thrombus and hence narrowing of artery. Abnormal vasospasm of the coronary arteries or coronary dissection may also lead to UA. UA is closely related to non-ST elevated myocardial infarction (NSTEMI) as they have the same pathogenesis and both are presented as chest pain. The only difference between them is that in NSTEMI, there is a rise in the cardiac biomarkers such as cardiac troponin or the MB isoenzyme of creatine phospokinase (CK-MB), which indicate s myocardial injury. In UA, the ischemia is not severe enough to cause damage to the myocardial cells and thus releasing these biomarkers in detectible amount. For the diagnosis of unstable, the patients history of anginal symptoms should be obtained. Physical examination like cardiac examination and vital signs monitoring may also be done. Patient with ongoing chest discomfort should have a 12-lead ECG performed within 10 minutes of onset to check if there is any ST-elevation or depression. If there is no ST elevation, STEMI will be ruled out and the level of serum cardiac biomarkers will be used to determine if the patient has UA or NSTEMI. Troponin I or T are normally the biomarker chosen for detecting myocardial cell death as it is detectable in the serum 3-6 hours after a myocardial infarction and remained raised for 14 days. If the serum troponin level is less than 0.01 Ã‚ ­g/L, then the patient will be diagnosed to have unstable angina. CK-MB may also be used when troponin test is not available. In Mr AR case, the results on the cardiac enzymes available, namely AST, CK and LDH are all non specific cardiac biomarkers as those enzy mes can also be elevated in skeletal muscle injury or liver disease. The treatment of UA can be divided into emergency treatment and secondary prevention treatment.2,3 Patients must rest in bed and ECG monitoring should be continued during the early phase of hospital stay. Sublingual glyceryl trinitrate (GTN) tablet or spray should be given for the relief of angina symptoms. GTN is a fast acting coronary vasodilators. Dilatation of veins going to the heart reduces ventricular volume and preload, while dilatation of systemic conductive arteries together with the decrease in ventricular volume causes a reduction in afterload. These effects will all reduce the myocardial oxygen demand.4 GTN also found to dilate collateral vessels, thus the areas of ischemia will receive a higher blood flow. If the chest pain is not relieved by GTN, intravenous morphine sulphate can be given to ensure patient comfort. Patient with ongoing chest pain or high risk patients should be given inravenous beta-blockers followed by oral route if there is no contraindication. Inter mediate or low risk patients can be given oral beta-blockers. If beta-blocker is contraindicated such as the in presence of uncontrolled heart failure, or the chest pain is not relieved by GTN and beta-blocker, nondihydropyridine calcium channel blocker can be given. Antiplatelet therapy should be given immediately by giving aspirin 300mg initially, followed by 75mg once daily for long term secondary prevention. In addition, clopidogrel 300mg should be given initially and 75mg daily thereafter for 3 months. Aspirin works by inhibiting the cyclooxygenase (COX) 1 enzyme on the platelet, thus preventing the production of thromboxane which stimulates platelet aggregation.5 Clopidogrel is an antiplatelet which acts by inhibiting adenosine diphosphate (ADP) from binding to its receptor, hence blocking the activation of ADP-mediated glycoprotein GPIIb/IIIa complex, a step involved in aggregation of platelets.6 Unfractionated heparin (UH) or low molecular weight heparin (LMWH) is an important antithrombotic agent in the management of UA. LMWH is normally preferred over UH as it can be given subcutaneously and no coagulation monitoring is needed. LMWH like enoxaparin should be given for 2-8 days. Heparin binds to antithrombin and the complex formed deacti vates a series of enzymes involved in the coagulation process. Thus thrombus formation will be inhibited.7 Patients with high risk of MI or death should also be given glycoprotein IIb/IIIa antagonist such as eptifibatide, tirofiban or abciximab. For the secondary prevention treatment, in addition to aspirin and clopidogrel, beta-blockers should be continued indefinitely. Statins can be started regardless of the patients cholesterol level for the preventing cardiovascular events. Statins are 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, which act by inhibiting the biosynthesis of cholesterol.8 Angiotensin converting enzyme (ACE) inhibitors are useful in patients with UA also. They work by inhibiting the production of angiotensin II which is a potent vasoconstrictor and reducing the breakdown of bradykinin which is a potent vasodilator.9 Evidence for the treatment of the conditions When the patient was admitted to the acute and emergency department, he was given clopidogrel 300mg, aspirin 300mg immediately and was then continued with long term treatment of 75mg of clopidogrel. The use of clopidogrel for the long term treatment of unstable angina was supported by two large trials. First, the CAPRIE trial which compare the beneficial effect of clopidogrel versus aspirin in patients at high risk of ischaemic event.10 In this trial, patients were either given 75mg clopidogrel once daily or 325mg of aspirin once daily. The clopidogrel group has a marginally lower risk of ischaemic stroke, myocardial infarction, or vascular death (5.32%) compared to the aspirin group (5.83%). The side effects reported were similar in both groups, indicating that clopidogrel has a comparable safety profile to that of aspirin. The second trial is the CURE Trial which investigate the beneficial effect of adding clopidogrel to aspirin therapy in patients with non-ST elevation acute coronary syndrome.11 In this trial, 12,562 patients were given either 300 mg clopidogrel innitially, then 75 mg once daily or placebo plus aspirin for 3 months to a year. It was found that there was a lower rate of death from cardiovascular causes, nonfatal MI or stroke in the clopidogrel group. However, the risk of major bleeding was significantly higher in clopidogrel group. Hence, it can be concluded that long term clopidogrel should be used in patients with acute coronary syndrome in addition to aspirin. In addition, according to a meta-analysis done by the Antithrombotic Trialists Collaboration, long term treatment of aspirin in the range of 75-150mg was found to be beneficial in patients with acute coronary syndrome. In cases where antithrombotic effect is needed immediately such as during acute attack of MI or UA, aspirin at a dose of 300mg should be given.12 In Mr AR case, only 300mg of aspirin was given in the acute and emergency department, no long term treatment of aspirin was given. This might be due to his newly diagnosed gastritis. NSAIDs were found to cause or worsen gastritis.13 According to the AHA/ACC guideline, clopidogrel will be the alternative for patients intolerant to aspirin due to gastrointestinal problems. According to a study done by Harker LA et al. where the tolerability and side effects of aspirin and clopidogrel were compared using the results from the CAPRIE trial, it was found that the group of patients receiving clopidogrel has a lower percentage of gas trointestinal side effects, with a rate 27.1% compared to 29.8% in those taking aspirin (p < 0.001).14 This finding support the reason behind clopidogrel being the only antiplatelet given to Mr AR. However, The difference in the incidence of side effects between the two treatment group was small and higher rate of occurrence of gastrointestinal problem in aspirin group might be due to the high dose of aspirin used (325mg). The policy of the ACC/AHA guideline of using clopidogrel instead of aspirin in patient with a history of GI complication was also refuted by Chan and colleagues.15 In this study, 320 patients who had recovered from aspirin-induced upper GI bleeding were given either 75 mg of clopidogrel daily or 80 mg of aspirin daily together 20mg of proton-pump inhibitor esomeprazole twice daily. When the patients were followed up after one year, it was found that patients in the aspirin group has a lower rate of recurrent upper GI bleeding compared to those receiving clopidogrel plus esomeprazole (8.6% versus 0.7%, P=0.001). No protective effect was conferred by esomeprazole in aspirin-induced lower GI bleeding. Hence, low dose aspirin is still deemed appropriate in Mr ARs case if given with a proton pump inhibitor or H2-antagonist like ranitidine. On day 1 Mr AR was given 60mg of enoxaparin immediately and twice daily thereafter. A comparison between the efficacy of UH and LMWH was carried out in the ESSENCE trial.16 In this trial, patients were allocated either subcutaneous enoxaparin plus placebo bolus and infusion or bolus and infusion unfractionated heparin plus placebo subcutaneous injection. In addition, they were all given oral aspirin. It was found that the enoxaparin group has a lower rate of recurrent angina, MI or death and also the need of revascularization process. Hence it was concluded that enoxaparin is more advantageous than UH, as there is little protein binding, longer plasma half life and more resistant to neutralisation by platelet factor IV as compared to UH. The dose given to Mr AR is justified according to a trial where the dose of enoxaparin was adjusted according to the weight of the patients. 17 It was found that giving 1mg/kg of enoxaparin to patients with UA or non-Q wave MI resulted in a lower ris k of major bleeding compared to giving a dose of 1.25mg/kg (6.5% versus 1.9%). Mr ARs weight was 59kg, thus a dose of 60mg is appropriate and evidence based. Sublingual GTN was given to Mr AR for the relief of his chest pain. According to the British Medical Journal evidence centre, no good evidence was found on the angina. There is one randomized placebo controlled study done by Karlberg et al. where they compared the effectiveness of intravenous GTN versus placebo in reducing ischaemic attack in unstable angina.18 In this trial, they found that patients given GTN have a fewer new onset of chest pain compared to placebo group. No trial was done to investigate the effectiveness of sublingual GTN in preventing ischaemic attack. However, according to a methodological study done by G Nyberg to determine the time of onset of sublingual GTN, it was found there was a significant reduction in the intensity of exercise induced chest pain and an improvement in the ST-depression when 0.5mg of GTN was given sublingually at the onset of chest pain.19 Hence, there is a consensus that sublingual GTN can be used for symptomatic control of unstable angin a. Mr ARs previous medications were continued during the hospital stay. Among those medications, perindopril, an ace-inhibitor, is also proved to be beneficial in the prevention of MI. There are two well known studies done on the effect of ace-inhibitors in preventing cardiovascular event in patients with cardiovascular disease, namely the HOPE trial and the EUROPA trial.20,21 In the HOPE trial, ramipril was chosen as the treatment drug. As for the EUROPA trial, perindopril was chosen to investigate if there is any beneficial effect in preventing MI, cardiac arrest or mortality in patients with stable coronary disease. It was found out that in the group of patients receiving perindopril, there was a 20% relative risk reduction in the primary end point as compared to the placebo group. Hence, it was concluded that perindopril should be given to all patients with coronary heart disease, including Mr AR who has unstable angina. In addition, Mr AR was continued with 40mg simvastatin once daily at night. According to a trial on simvastatin, it was found that giving simvastatin to high risk patients lowers their cholesterol level and reduces the incidence of cardiovascular events.22 In this trial, 20536 adults in the UK with high risk of getting cardiovascular event were given simavastatin 40mg daily or placebo. It was found that the simvastatin group has a lower percentage of all cause of death (12.9%) and major vascular event (19.8%) compared to the placebo group (14.7% and 25.2% respectively). There was a difference of about 1.0mmol/L in the LDL cholesterol level between the two groups after treatment regardless of the initial cholesterol level. This indicates that there is a reduction in the LDL cholesterol level in the simvastatin group which is independent on the initial cholesterol level. For patient given simvastatin, the risk reduction of the first major vascular event is similar no matter the patient s were taking ace inhibitors, aspirin, beta blockers or antihypertensive drugs or not. This shows that simvastatin provides additional benefits when added to the existing treatment with these drugs. Thus, it can be concluded that simvastatin will be beneficial to Mr AR who was taking ace inhibitor and antihypertensive drugs concurrently. Mr Ar was newly diagnosed with gastritis and was commenced on IV ranitidine. In a double blind clinical study, patients diagnosed with gastritis were given 300mg ranitidine daily for 4 weeks or placebo only.23 It was found that patients from the ranitidine group improved significantly faster than the placebo group and 80% of the patients had their symptoms completely resolved. Only 45% of the patients from placebo group achieved improvement in their symptoms while the remaining showed no change in their gastritis. Hence, it was concluded that ranitidine is an effective treatment option for gastritis. However, this trial only involved 52 patients and this small sample size renders the finding from trial inconclusive. In another trial where the effectiveness of ranitidine and sucrafate was compared, it was found out that both have a similar activity in relieving the symptoms of gastritis.24 77.6% of the patients receiving sucralfate and 79.4% from the ranitidine group had their symptom s completely resolved at the end of the study period (8 weeks). However, ranitidine was found to act faster in relieving pain compared to sucralfate. Hence, it can be concluded that the management of Mr ARs gastritis with ranitidine is justified. Mr AR was given nifedipine 10mg for the treatment of his hypertensive urgency. Even though nifedipine was found to be effective in reducing blood pressure within 20 minutes, this fast release, short-acting calcium channel blocker are not recommended in this case as Mr AR did not receive any beta-blocker before. According to the results obtained from the Holland Interuniversity Nifedipine/metoprolol Trial (HINT), monotherapy with nifedipine in patients with unstable angina naà ¯ve to beta blockers was associated with a higher risk of recurrence ischaemic attack or MI.25 The event rate ratio compared to placebo for beta blocker naà ¯ve, nifedipine only group was 1.15. As for the group receiving both nifedipine and metoprolol, the ratio was lower (0.80). Patients who were already receiving beta blockers and were added with nifedipine also showed lower rate ratio (0.68). Hence, it was concluded that nifedipine was only beneficial in patients who were treated with beta blocker at the sa me time. Moreover, it was found from the Trent study that nifedipine does not show any beneficial effect in patients with MI.26 In this trial, the death rate for patients receiving nifedipine 10mg four times daily and placebo was similar. When the number of death and MI were compared among patients taking beta blocker and not taking beta blocker among admission, it was found that the latter group has a higher rate of death and MI. This result is comparable to those from the HINT trial. Hence, the use of nifedipine in treating Mr ARs hypertensive urgency is not justified, other drug should be chosen. Conclusion The immediate treatment of UA with high dose of antiplatelet agent aspirin and clopidogrel together with the antithrombotic agent LMWH are justified as they help preventing the progression of UA to MI. Sublingual GTN on the other hand helps relieving his chest pain. As for his previous perindopril and simvastatin that were continued, these help in preventing recurrent angina also. Choosing clopidogrel for the long term prevention treatment of UA due to the presence of gastritis might not be the best option for Mr AR. Once his gastritis has resolved, life-long aspirin at the dose of 75mg should be added in with oral ranitidine 300mg twice daily prescribed as prophylaxis against NSAID induced gastritis. However, the use of nifedipine in the management of his hypertensive urgency is not justified. Instead, he should be given labetalol, atenolol or clonidine which were found to be better alternatives to nifedipine in treating hypertensive urgency.27 PATIENT MEDICATION PROFILE Patient details Name: AG Consultant: General Practitioner: Address: Gender: Male Weight: 59kg Height: 168cm Community pharmacist: Age: 41 Known sensitivities: NKDA Social history: Non-smoker, No alcohol abuse. Patient hospital stay Reason for admission Admission date: Chest pain. Discharge date: Relevant medical history Relevant drug history Date Problem description Medication Comments 1994 Pacemaker fixed Warfarin 5mg OD Atrial fibrillation 2007 Pacemaker not functioning, did not go for replacement due to financial constraint T digoxin 125mcg OD Atrial fibrillation 2007 Angiogram, 2 blocked vessels T frusemide 40mg BD Hypertension Hypertension Perindropil (coversylƒ’) 8mg OD Hypertension T amlodipine 10mg OD Hypertension Hydrochlorthiazide 25mg OD Hypertension T simvastatin 40mg ON Prevention of cardiovascular event Prescribed medication Route of administration Start Stop Nifedipine (adalat) 10mg PO Day 1 Aspirin 300mg PO Day 1 Day 1 Clopidogrel (plavixƒ’) 300mg PO Day 1 Day 1 Clopidogrel (plavixƒ’) 75mg OD PO Day 2 Enoxaparin (Clexaneƒ’) 60mg stat, BD subcutaneous Day 1 GTN 1 tablet PRN sublingual Day 1 Simvastatin 40mg ON PO Day 1 Amlodipine 10mg OD PO Day 1 Hydrochlorothiazide 25mg OD PO Day 1 Warfarin 5mg OD PO Day 1 Furosemide (Lasix) 40mg stat, BD IV Day 1 Day 3 Furosemide 40mg BD PO Day 3 Perindopril (Coversylƒ’) 8mg OD PO Day 1 Ranitidine (zantac) 50mg tds IV Day 1 Digoxin 125mcg OD PO Day 1 Clinical/ Laboratory Tests Date Results Potasium (3.5-5.0 mmol/L) Day 2 3.3 BP Day 2 150/118 Day 3 134/100 Day 4 122/86 Pharmaceutical Care Plan Care Issue Action Actual output/ Desired output Long term treatment with aspirin. Patient should be given 75mg of aspirin for the secondary prevention of UA. Patient has gastritis. He should be started on long term treatment of aspirin once his gastritis has resolved and ranitidine should be prescribed as prophylaxis against NSAIDs induced GI complications. Long term treatment with beta blockers. Beta blocker should be given to the patient as the secondary prevention treatment. Patient should be started on labetalol 100mg twice daily and titrate up to 200mg twice daily. Inappropriate use of nifedipine for the management of hypertensive urgency. Nifedipine should be substituted with labetalol 200-300mg every 3-4 hours when required. Not taken. Interaction between digoxin and diuretics when hypokalaemia occur. Potasium level should be monitored. Inform the patient on signs and symptoms of digoxin toxicity. Patients potassium level was lower than the normal range on day 2. He should be given potassium sparing diuretics or potassium supplement if the potassium level keeps going down. Monitoring should be continued. High risk of bleeding due to warfarin, aspirin, clopidogrel and enoxaparin. Bleeding tendency should be monitored. Patient should be told to inform the GP if there is any unusual bleeding like blood in the stool. Patients INR and prothrombin time were within the normal range. Monitoring was continued. Changing of IV ranitidine to oral ranitidine. Patient should be switched to oral ranitidine150mg twice daily after being discharged. Not taken. GTN for relief of angina symptoms. Patient should be prescribed GTN spray or sublingual tablet for the relief of chest pain shoul the patient has another angina attack. GTN sublingual tablet was prescribed as discharge medication. Poor patient compliance Patient should be informed on the reason behind taking his medication, the importance of compliance. Compliance aid should be given. Patient was counselled on the importance of compliance. Side effects of simvastatin -muscular side effects -liver disease Patient should be advised to report immediately any unexplained muscle pain, weakness nor tenderness. Regular LFT monitoring should be done. No monitoring of cholesterol level. Cholesterol level should be monitored suring the hospital stay so that the dosage of simvastatin can be adjusted accordingly. Cholesterol level should be maintained below 5.2mmol/L. Patient education on healthy lifestyle. Patient should be told on the importance of low salt diet for his HT and encouraged to exercise more. Patient was counselled on the importance of healthy lifestyle before being discharged.

Shakespeares Macbeth does not Follow Aristotles Standards for a Trage

Macbeth does not Follow Aristotle's Standards for a Tragedy There have been many great tragic authors throughout history: Aeschylus, Euripides, and Sophocles from ancient Greece; Corneille and Hugo from France; Grillparzer and Schiller from Germany; and Marlowe, Webster, and Shakespeare from England. From this long list of men, Shakespeare is the most commonly known. Many Shakespearean critics agree that Romeo and Juliet and Hamlet are great tragedies. Many critics also claim that Macbeth is a tragedy, but if one follows Aristotle's standards for a tragedy, Macbeth would not be a tragedy To really determine if Macbeth is a tragedy according to Aristotle, one must first look at his guidelines. The majority of Aristotle's standards relate to the downfall of the central character. To set the character up for a downfall, Aristotle thought he or she should be of the middle class. This was because he felt the poor had nothing to lose. He also felt the downfall should be caused by a fatal flaw. Another characteristic Aristotle believed was important, was a conflict between the central character and a close friend or relative. According to him, the main character should also have an enlightenment at the moment of his or her downfall. Aristotle also believed that the feelings of pity and fear should be felt by the audience during the play. He thought that these feelings would lead to a catharsis, or release of emotions. Although most of Aristotle's characteristics of a tragedy had to do with the downfall, he had two that did not. First, he thought the central character should not be totally good or evil. This was based on the belief that the ruin of a totally good character would be too painful, and the ruin of a totally bad char... ... not even thank is wife for the plan that made him king. Due to Malcolm's final speech, the reader is left with positive, not negative feelings. Overall Macbeth is not a tragedy according the Aristotle's standards. Macbeth's downfall does follow the guidelines: he has something to lose, he has a downfall, and he has conflicts with his friends and relatives during his downfall. But, the heart of the play, which is the emotions created, just do not follow Aristotle's standards. The reader should feel pity, and grieve. Yet, there is no reason to feel this way because Macbeth is all evil, and in the end, the "good guy" is restored to power. Shakespeare put forth good effort in trying to make Macbeth a tragedy, but he came up too short. Works Cited: Shakespeare, William. â€Å"Macbeth.† The Complete Works of Shakespeare. Ed. David Bevington. New York: Longman, 1997.

Good vs. Evil †Analytical Sentence Outline Essay

Theme: Good and Evil Create a SocietyParagraph 1:CENTRAL IDEA: Conflicts heavily arise between the two topics of good and evil. THESIS SENTENCE: Through common stories good and evil are portrayed through both protagonist and antagonist view, creating morals and opinions, and how societies views have changed over time. Paragraph 2:TOPIC SENTENCE: Common stories portray good and evil through both a protagonist and antagonist view. Paragraph 3: TOPIC SENTENCE: Significant morals and opinions are shown in stories made up of good and evil. Paragraph 4: TOPIC SENTENCE: Societies views have changes over time by the reality brought out in good and evil. Paragraph 5: CONCLUSION: Good and evil represented the two different thoughts that occur through the mind of people during their extensive lifetime. Conflicts heavily arise between the two topics of good and evil. These conflicts can be extremely realistic or notably exaggerated. They both represent two powers that involve different emotions within your heart. Through common stories, good and evil are portrayed through protagonist and antagonist view, creating morals and opinions, and how society’s views have changed over time. Common stories portray good and evil through a protagonist and antagonist view. The first thing I think of when I hear â€Å"good vs. evil† would be a fairy tale. As in most fairy tales, there is always a good guy and a bad guy. An example of this kind of story would be Beowulf, where as Beowulf is the protagonist and Grendel is the antagonist. Grendel would come into the town and cause chaos every night, until Beowulf came along and had the courage to stand up to the beast. He killed Grendel bare handedly and saved the city from losing any more lives. See more: 5 paragraph essay format People have come to expect the good guy to always save the day, whether he dies or not. Significant morals and opinions are shown in stories made up of good and evil. Teachers have their students read fairy tales at a young age to teach morals of everyday life. For instance, in the tale of Beauty and the Beast, a strong moral is placed. The author made it clear to their audience that â€Å"you should not judge a person by the way they look. † Another example of morals in good versus evil epics could be Cinderella, where the evil stepsisters learn that being cruel can come back in the long run to haunt you. Society’s views have changed over time by the reality brought out in good and evil. People used to feel certain ways about different issues, until morals came out of good and evil tales. Slavery was once considered a good thing. Slaves helped do all the hard work the owners didn’t have time for. Segregation was also considered a good thing. Schools, businesses, and even public restrooms were segregated, keeping the â€Å"dirty† black from disturbing the â€Å"clean† white. Martin Luther King Jr. came along and made a statement. He proved to everyone that slavery and segregation was evil and not necessary for the U. S. The views on racism have since then changed, making everyone have equal rights. Good and evil represented the two different thoughts that occur through the mind of people during their extensive lifetime. The thought of good represents a hero and peace in a fairy tale, whereas the thought of evil comes to mind views of devils and bad guys. People’s heart stings sometimes get pulled while rendering these subjects, which brings together the powers of good and evil.

My High School Experience Essay

My high school experience has been a success for me to get to college by taking all of the class I needed to get this far. I have came a long way during my high school career because I really thought I wouldn’t have made it this far due to struggling to keep my grades up but as I started it’s not hard at all to keep them up you just have to try hard and get the job done. Although being in Upward Bound has help me accomplish these goals to make it his far from ninth grade to twelfth grade. Due to being in Upward Bound I have learned a lot of things such as you have to do things own your own because nothings ever going to be handed to you. Now that I finally realize that I’m a senior in high school and that time has real passed by now I’m standing here with a diploma something I’ve been waiting for all my life. As I look back I’m not ready to leave high school yet because now I’m own my own in college and there’s no one there to t ell me what to do . As everyone would say â€Å"welcome to the real world.† Some people think of this as yes I’m finally out of the house with my mother and that their going to have fun and make new friends and party. I think of this as I want to go to college and be successful in life, get the job done, get my associate’s degree and move on up to the real world also I would love to be on the dean’s list every semester that would be a really great honor to me to let me know that I have did what I had to do in college and not just played the whole time .I know that I will miss it here being with friends and goofing around with others. But now it is for me to step on up to a new chapter in life by going to college and doing what I like to do working with children and their families. I hope that all of us will work hard to accomplish our dreams and do what we got to do to get what we want . It want be that hard I hope only if you just try and put your mind to it to do it. It want be as hard as you make it just do your best. I’m glad that all of us have made it to the end now that we can say that we â€Å"started from the bottom now were here.†Now that I have accomplished my task for today I would ask you to encourage me and others to always do their best in anything cause you never know what your going to get out of being the best that we can be and I hope you take this with you to remember the class of 2015.

Calcite and Aragonite in Earths Carbon Cycle

Calcite and Aragonite in Earth's Carbon Cycle You may think of carbon as an element that on Earth is found mainly in living things (that is, in organic matter) or in the atmosphere as carbon dioxide. Both of those geochemical reservoirs are important, of course, but the vast majority of carbon is locked up in carbonate minerals. These are led by calcium carbonate, which takes two mineral forms named calcite and aragonite. Calcium Carbonate Minerals in Rocks Aragonite and calcite have the same chemical formula, CaCO3, but their atoms are stacked in different configurations. That is, they are polymorphs. (Another example is the trio of kyanite, andalusite, and sillimanite.) Aragonite has an orthorhombic structure and calcite a trigonal structure. Our gallery of carbonate minerals covers the basics of both minerals from the rockhounds viewpoint: how to identify them, where theyre found, some of their peculiarities. Calcite is more stable in general than aragonite, although as temperatures and pressures change one of the two minerals may convert to the other. At surface conditions, aragonite spontaneously turns into calcite over geologic time, but at higher pressures aragonite, the denser of the two, is the preferred structure. High temperatures work in calcites favor. At surface pressure, aragonite cant endure temperatures above around 400Â °C for long. High-pressure, low-temperature rocks of the blueschist metamorphic facies often contain veins of aragonite instead of calcite. The process of turning back to calcite is slow enough that aragonite can persist in a metastable state, similar to diamond. Sometimes a crystal of one mineral converts to the other mineral while preserving its original shape as a pseudomorph: it may look like a typical calcite knob or aragonite needle, but the petrographic microscope shows its true nature. Many geologists, for most purposes, dont need to know the correct polymorph and just talk about carbonate. Most of the time, the carbonate in rocks is calcite. Calcium Carbonate Minerals in Water Calcium carbonate chemistry is more complicated when it comes to understanding which polymorph will crystallize out of solution. This process is common in nature, because neither mineral is highly soluble, and the presence of dissolved carbon dioxide (CO2) in water pushes them toward precipitating. In water, CO2 exists in balance with the bicarbonate ion, HCO3, and carbonic acid, H2CO3, all of which are highly soluble. Changing the level of CO2 affects the levels of these other compounds, but the CaCO3 in the middle of this chemical chain pretty much has no choice but to precipitate as a mineral that cant dissolve quickly and return to the water. This one-way process is a major driver of the geological carbon cycle. Which arrangement the calcium ions (Ca2) and carbonate ions (CO32–) will choose as they join into CaCO3 depends on conditions in the water. In clean fresh water (and in the laboratory), calcite predominates, especially in cool water. Cavestone formations are generally calcite. Mineral cements in many limestones and other sedimentary rocks are generally calcite. The ocean is the most important habitat in the geological record, and calcium carbonate mineralization is an important part of oceanic life and marine geochemistry. Calcium carbonate comes directly out of solution to form mineral layers on the tiny round particles called ooids and to form the cement of seafloor mud. Which mineral crystallizes, calcite or aragonite, depends on the water chemistry. Seawater is full of ions that compete with calcium and carbonate. Magnesium (Mg2) clings to the calcite structure, slowing down the growth of calcite and forcing itself into calcites molecular structure, but it doesnt interfere with aragonite. Sulfate ion (SO4–) also suppresses calcite growth. Warmer water and a larger supply of dissolved carbonate favor aragonite by encouraging it to grow faster than calcite can. Calcite and Aragonite Seas These things matter to the living things that build their shells and structures out of calcium carbonate. Shellfish, including bivalves and brachiopods, are familiar examples. Their shells are not pure mineral, but intricate mixtures of microscopic carbonate crystals bound together with proteins. The one-celled animals and plants classified as plankton make their shells, or tests, the same way. Another important factor appears to be that algae benefit from making carbonate by ensuring themselves a ready supply of CO2 to help with photosynthesis. All of these creatures use enzymes to construct the mineral they prefer. Aragonite makes needlelike crystals whereas calcite makes blocky ones, but many species can make use of either. Many mollusk shells use aragonite on the inside and calcite on the outside. Whatever they do uses energy, and when ocean conditions favor one carbonate or the other, the shell-building process takes extra energy to work against the dictates of pure chemistry. This means that changing the chemistry of a lake or the ocean penalizes some species and advantages others. Over geologic time the ocean has shifted between aragonite seas and calcite seas. Today were in an aragonite sea that is high in magnesium- it favors the precipitation of aragonite plus calcite thats high in magnesium. A calcite sea, lower in magnesium, favors low-magnesium calcite. The secret is fresh seafloor basalt, whose minerals react with magnesium in seawater and pull it out of circulation. When plate tectonic activity is vigorous, we get calcite seas. When its slower and spreading zones are shorter, we get aragonite seas. Theres more to it than that, of course. The important thing is that the two different regimes exist, and the boundary between them is roughly when magnesium is twice as abundant as calcium in seawater. The Earth has had an aragonite sea since roughly 40 million years ago (40 Ma). The most recent previous aragonite sea period was between late Mississippian and early Jurassic time (about 330 to 180 Ma), and next going back in time was the latest Precambrian, before 550 Ma. In between these periods, Earth had calcite seas. More aragonite and calcite periods are being mapped out farther back in time. Its thought that over geologic time, these large-scale patterns have made a difference in the mix of organisms that built reefs in the sea. The things we learn about carbonate mineralization and its response to ocean chemistry are also important to know as we try to figure out how the sea will respond to human-caused changes in the atmosphere and climate.