Managing Operations and the Supply Chain Essay Example | Topics and Well Written Essays - 1500 words

Managing Operations and the Supply Chain - Essay Example In quality improvement teams, employees from the same department, division, or team of the organization brainstorm to identify a list of problems to resolve. The advantage of this approach is that the employees characteristically have the best view of their work environment and associated problems and can develop ideas to improve efficiency and effectiveness. The drawback to this is that the problems chosen by the group may or may not contribute to the Tower Records overall goals. Tower Records with a focused success paradigm can multiply the return on its investment for its quality efforts over an organization without a clear vision. With the myriad of problems any given group can identify, it is important that resources be allocated for problem solving that can contribute positively to the successful implementation of Tower Records strategy. Based on such considerations, it is evident that the need for specific criteria and models to verify the quality fit between the Tower Records and the business atmosphere in that it operates, and to effectively and efficiently manages the relationships among the actors within the network. Such relationships, in fact, are characterised by many-to-many connections instead of more traditional one-to-one. For that reason, a deep revision of current managerial techniques is dramatically requested. Regardless of huge number of works on this subject, (Harland et al., 2001; Lamming et al., 2000), reliable criteria for the analysis and the evaluation of Tower Records networks, based on the relationships among economic actors interconnected through Internet, are not yet available. Accordingly, managers usually operate according to empirical methodologies that often do not assure optimal quality performances. In order to contribute towards the solution of such a problem, preliminarily examined factors that mostly affect the Tower Records quality performances. It may be assumed that effectiveness and efficiency of Tower Records depend on the coherence between the characteristics of the atmosphere in that the embedded actors operate and the way in that relationships among embedded actors are managed. The management of such relationships, consecutively, is based on the following three factors (Cucchiella et al., 2002): The structures adopted to organize the relationships among the actors of the network (Tower Records organisational structures). The criteria adopted to manage such relationships (managerial criteria); and The activities to be carried out for coordinating the relationships (critical activities). With respect to the Tower Records organisational structures, Tapscott et al. (2000) define five types of b-web adopted to manage relationships among embedded actors based on the level of product-service value integration (high vs. low) and control type: Agora, Aggregation, Value chain, Alliance, and Distributive network. According to Nkkentved (2000), the managerial criteria may be instead, defined on the basis of two variables, the market fragmentation and the product/process complexity. Consequently, six types of criteria may be identified: Auction house; Independent

Respond to classmate Essay Example | Topics and Well Written Essays - 250 words

Respond to classmate - Essay Example Diversity brings together people with different beliefs and cultures. These people view situations in different perspectives and if brought together, they will make good ethical decisions. If the instructors had employed a check and balance system, the students would have been placed in groups. Moreover, the instructors would have demanded a report on each stage of the processes; hence, ethics violations could have been avoided. I appreciate that I have been able to understand the relationship between ethical decision-making and diversity because it is critical and exists. A combination of the two methods of implementing programs leads to successful teaching. Since realists hold to the traditional scientist values and constructivists on the other hand, implement art and creativity in the science-based disciplines, the science aspects taught are well absorbed by the students. The creativity aspect encompasses modern ways to handle situations (Rainer, 2011). I agree with you because, for the millennials, traditional values demoralize them as they engage in some extra-curricular school activities as well as science-based disciplines (Rainer, 2011). This was evident from few numbers of students that participated in sports as well as school clubs. A new club introduced in the school encompassed designing projects using latest technologies. The students were creative and many projects involved a lot of science technologies as well as engineering. They then converted their free time to designing projects and this way, they perfected their science-based skill s. It is therefore evident that these two methods, when combined together yield better

Discussion Assignment Example | Topics and Well Written Essays - 250 words - 26

Discussion - Assignment Example It is unfortunate that judges and other top government officials have personal immunity, which comes by professional courtesy and law. After one going through several blogs, one realizes that tyranny is greatly used as a strategy and the best example to illustrate this is the fact that Hamilton had tactics that worked with regard to tyranny. It is obvious that words are not sufficient and there must be true change in the United States of America when it comes to industrial espionage since the threat is not overblown. The main reason behind the US changing is the intelligent activity that the United States gathers foreign intelligence similar to that gathered by all nations globally. Being the superpower country, there must be some data protection, which can only happen with the help of changing the industrial espionage. Having data protection will be beneficial to almost every American citizen but mostly the leaders. Claims that America spies on other nations mean that the threat is not overblown but true change in industrial espionage will cover up

Respond to classmate Essay Example | Topics and Well Written Essays - 250 words

Respond to classmate - Essay Example Diversity brings together people with different beliefs and cultures. These people view situations in different perspectives and if brought together, they will make good ethical decisions. If the instructors had employed a check and balance system, the students would have been placed in groups. Moreover, the instructors would have demanded a report on each stage of the processes; hence, ethics violations could have been avoided. I appreciate that I have been able to understand the relationship between ethical decision-making and diversity because it is critical and exists. A combination of the two methods of implementing programs leads to successful teaching. Since realists hold to the traditional scientist values and constructivists on the other hand, implement art and creativity in the science-based disciplines, the science aspects taught are well absorbed by the students. The creativity aspect encompasses modern ways to handle situations (Rainer, 2011). I agree with you because, for the millennials, traditional values demoralize them as they engage in some extra-curricular school activities as well as science-based disciplines (Rainer, 2011). This was evident from few numbers of students that participated in sports as well as school clubs. A new club introduced in the school encompassed designing projects using latest technologies. The students were creative and many projects involved a lot of science technologies as well as engineering. They then converted their free time to designing projects and this way, they perfected their science-based skill s. It is therefore evident that these two methods, when combined together yield better

Importance of Historical Perspectives Essay Example for Free

Importance of Historical Perspectives Essay The organised use of labour or Management as we now call it, is as old as time. However it was only in the 19th century that management and the idea of management thought emerged as an important element of political, economic and social development. I believe that historical perspectives have been critically important to the development of management thought through the centuries. Management ideas have been developed out of social and cultural circumstances, over time the social and cultural circumstances have radically changed and developed but the principle of management and management thought has been slow in keeping up with these developments. From my reading, I would argue that there have been three main phases that have fundamentally shaped management thought since ancient times. These phases are; the early autocratic management approach, the change in management thought following the reformation and thirdly, the new work practices required to support the industrial revolution. From my research, it is evident that major historical events have also had an important role to play in the development of different management styles and structures. In ancient times, management of people was purely autocratic. Many of the work force in these times were slaves. This early practise of management seen in ancient Egypt, continued through to feudal times. It was very effective in supporting some of the great construction projects which ancient Egypt is famous for, such as the building of the pyramids, the irrigation of the Nile and the building of the tombs in the Valley of the Kings. Similarly in ancient China, the building of the Great Wall of China. These great works provide us with evidence of a very organised and autocratic approach to the use of labour and also project management skills . This early autocratic period of management was heavily dominated by cultural values such as; fear of punishment, fear of god, where people had no sense of individual achievement and they could only look forward to a better life after death. This form of management continued through the middle ages and in these non-industrialised circumstances there was no â€Å"no need to develop a formal body of management thought†(Wren Bedeian, 2011: 37) As long as society was dominated by fear and oppression this form of management was sustained. As long as Christianity and the divine right of kings maintained their hold on society, management thought could not evolve and develop. However, these feudal times where religion was invincible and demanded total subservience ere coming to an end. The crusades were a major catalyst for change in these times and by weakening the strength of the catholic church they were the beginning of a cultural rebirth which led to the protestant reformation. With the reformation came the protestant work ethic which I would argue has transcended the history of management and has fundamentally changed work practises opening the door to completely different and new management styles and structures. Prior to this commerce was viewed as an evil that corrupted peoples’ minds and the idea of trade could undermine the obedience demanded by the catholic church. Max Weber in â€Å"the protestant ethic and spirit of capitalism† urges strongly that the spirit of capitalism grew out of Protestantism and the protestant work ethic. (Wren Bedeian, 2011: 26) It is clear that the transformation in attitudes in society due to the reformation brought with it the need for new management structures which would support creativity and competitiveness. These changes did not happen quickly, but they were pivotal in the fundamental shift to the organisation of labour being managed by many people and many different types of people rather than the autocratic few. These new managers began to think about personal gain and had to consider the best ways to achieve these gains. The shift to personal gain was accompanied by the strengthening of national economies in Europe and further afield as new countries and colonies were being discovered and established. The scene was being set for the industrial revolution. Historical perspectives were changing and along with them, new principles in management thought were emerging. Adam Smith was one of the evangelists of management thought during the early stages of the industrial revolution. One of Smith’s new thoughts on management was that the market economy would be se self regulating, that is to say that the market would be ruled by the â€Å"invisible hand†(Wren Bedeian, 2011: 34). His other contribution were his thoughts on the division of labour culminating in the substantial productivity that the use of technology brought to replace human man power. Smith’s principles are fundamental to modern management thought. The industrial revolution brought with it the move from agrarian life to urban living. Production became large scale and the increasing number of factories coming into production demanded more managers who would have to be capable of successfully organising and managing all aspects of these new work places. There is no doubt that historical perspectives have been mportant in bringing about great changes for the better in management thought as evidenced by the evolution of the three phased covered herein. However I would conclude, that despite the advantages of having historical perspectives, society and the management of society does not really learn from these perspectives. I think this is well summarised in Will Durant’s quote in â⠂¬Å"the story of civilization part 1† where he states that â€Å" a nation is born stoic and dies epicurean†(Durant, 1935: 259). There is no clearer example of this than in Ireland today. We have spent centuries struggling against the autocratic management of Irish society both by the catholic church and by British rule. The adversity of these times was eventually replaced by the development of new management structures bringing with them creativity and competiveness. However, as with many developing societies and civilisations, with this development came affluence and opportunism which in turn undermined the integrity of these management structures. Like the Epicureans, poor thought was given to how this would impact tomorrow. So as in Greece and Rome, the lack of long term prudent management and the lack of learning from the historical perspectives on management thought have meant that we have not escaped the Epicurean death blow that has been rendered to Ireland.

Case Study: Hypertension in Pregnancy

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

Separate Peace Essay: Boys to Men :: A Separate Peace Essays

A Separate Peace: Boys to Men World War II influenced the boys in the novel A Separate Peace, written by John Knowles, by making them grow and mature more quickly than they would have had there not been a war. The war makes some boys stronger and more ready for whatever life would bring, while in others it disables them to the point that they cannot handle the demands of life. The maturing influence of the war on Finny is a considerable one, even though it does not seem to the other boys that he is growing up at all. Gene's jealousy leads him to the point where he has to destroy Finny's greatest asset, his skill in sports, just so that he does not have to be the "popular guy's friend.† Gene knocks Finny off the tree limb and he breaks his leg. Everyone at Devon, except for Finny, suspects that Gene, and not Finny’s loss of balance, caused him to fall off the branch. Finny's outlook on the whole situation is very grown up. He does not blame anyone but himself, even though the accident is not his fault at all. Finny seems as though he will never grow up; his immaturity is shown through his silly denial of the war's existence and his habit of always coming up with strange things to do just for fun. Inside he is suffering with the anger and hurt of being excluded from the one thing that he wants to do most: fight in the war. This is an excellent example of how the war suddenly makes the boys grow up into men. They have to face adulthood, and in order to do that, they have to become adults. ***I think you could develop this more. You say that Finny began as immature, but his reaction to his accident is very grown up. Discuss specifically how the accident has made him become an adult. Why did he not react immaturely this time? Another boy in the story who was matured by the war was Leper. When he sees the movies about the ski troops, he thinks that it looks fun and he surprises everyone by enlisting. Leper does not quite know what he is getting into when he enlists. He thinks that it looks like a fun ski trip; he can serve his country and ski around the world at the same time.