Case Study: Patient With Shortness Of Breath

Case Study: Patient With Shortness Of Breath Patient Identity The patient is a 54 year old female, Mrs SK who is a housewife with a BMI of 25.7kg/m2. Presenting Complaints She was brought in to the Accident and Emergency (AE) department, complaining of shortness of breath (SOB) and a productive cough. History of Presenting Complaints The patient was experiencing SOB for the past 2-3 days, and was progressively worsening on the day on admission. It was not associated with chest tightness and she was able to sleep the night before. She was also having persistent productive cough with white sputum since she was last discharged 12 days ago. Past Medical History She was diagnosed with diabetes mellitus and hypertension 8 years ago and has history of gastritis for the past 5 years. She was newly diagnosed with bronchial asthma in her last admission two weeks ago. Social History The patient is a widow since 6 years ago and is a housewife with 3 children. She stays in a factory area and has a cat at home. She is a non-smoker and a non-alcoholic. Family History Her mother and father have no known medical illness, but she has a cousin who suffers from bronchial asthma and is frequently admitted to the wards. Drug History The patient was on Salbutamol and Budesonide inhalers, 200mcg when necessary and 200mcg once at night respectively for her bronchial asthma. For her hypertension, she was on 40mg Telmisartan tablets once at night. She was also taking Gliclazide tablets, 80mg twice daily and Metformin tablets, 500mg three times a day for her diabetes mellitus. For her hypercholestrolaemia, the patient was taking Lovastatin tablets 20mg once at night. Based on the Morisky Scale, she was compliant with her medication and she had no known drug allergy. Examination Details On examination, the patient was alert and conscious. She was pink and appeared to be fairly hydrated. She was also able to speak in full sentences, and was not tachypnoeic. A Chest X-ray showed that there was a pneumonic consolidation at the right lower lobe of her lungs. Her blood pressure (BP) was 152/82mmHg, pulse rate (PR) was 109 beats per minute (bpm) and was afebrile. Her oxygen saturation (SpO2) was 96% under 3 litres of oxygen and her blood glucose was measured to be 4.7mmol/L. Investigations Upon admission, standard laboratory investigations were carried out and were obtained. From the renal function test, it was seen that the patient had a low potassium level of 2.8mmol/l and her calculated creatinine clearance was 60.0ml/min which indicated that she had mild renal impairment. The liver function test showed that she had normal liver function. The following shows the results that were out of the reference values for her haematological tests. C-Reactive Protein (CRP) 31.1 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Erythrocyte Sedimentation Rate (ESR) (0 15 mm/hr) 110 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Haemoglobin (Hb) (13.5-18 g/dl) 10.3 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Haematocrit (0.36-0.46 L/l) 0.303 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Red Blood Count (RBC) (3.8-4.8 x 1012 /l) 3.45 à ¢Ã¢â‚¬  Ã¢â‚¬Å" White Cell Count (WCC) (4-11 x 109 /l) 15.1 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Neutrophil (Neutro) (2 7.5 x 109 /l) 10.57 à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Diagnosis/Impression Patient was initially diagnosed with Acute Exacerbation of Bronchial Asthma (AEBA) secondary to an upper respiratory infection (URTI) to rule out pneumonia. However, later in the day when the chest X-ray came back, she was diagnosed with pneumonia with right parapneumonic effusion. Management Plan The patients current medication was continued and was given 3 litres of oxygen via a nasal prong (NP). She was commenced on prednisolone tablets, 30mg once a day and was given nebulised Combivent (Ipratropium 20mcg/salbutamol 100mcg), every 4 hours. Her peak expiratory flow rate (PEFR) and SpO2 was to be monitored. Antibiotics were kept in view to be started if necessary after the total white blood count results came back. Clinical Progress Upon admission, the patient was afebrile, was tolerating orally well, did not have any sorethroat but was having a non productive cough. An echocardiogram (ECG) was done and it showed that she had sinus rhythm with no ischaemic changes. As her chest x-ray showed a right lower zone consolidation, she was diagnosed with pneumonia. She was immediately commenced on 2g Ceftazidime intravenously, and then continued on 1g three times a day. She was also under nebulised combivent every 6 hours. Her metformin and gliclazide was stopped and she was started on subcutaneous 10 units of Humulin  ® three times a day and 12 units of Humulin N once at night. On Day 2 of her stay, her blood results came back and as she has low potassium levels, she was given 15mls of Mist KCl three times daily and two Slow K tablets once daily. She was still complaining of cough without sputum and was given 15mls of Benadryl (diphenhydramine) syrup three times a day. The patient did not have any major complaints on the third day and was tolerating orally well. There was no SOB seen and she had good inhaler technique. She was then taken off the nebulizer combivent and the oxygen. By day 4, the patient was comfortable, and her cough and sputum had decreased. Examination on her lungs showed that she had prolonged expiratory phase. She was stopped on the Benadryl as well as Mist KCl and Slow K. After reinforcement on the inhaler technique by the pharmacist, the patient was discharged on day 5 as she was afebrile and had minimal cough. On discharge, she was then switched back to her oral hypoglycaemics and her intravenous antibiotic was switched to oral Cefuroxime 500mg twice daily for the next 10 days. She was also given Neulin SR 250mg once at night. Table 1 shows the vital signs chart for Mrs SK throughout her hospital stay. Table 1: Vital Signs Chart Day Time BP (mmHg) PR (bpm) SpO2 Blood Glucose (mmol/l) 1 13.00 178/102 109 100% 6.9 14.00 152/82 109 98% à ¢Ã¢â‚¬  Ã¢â‚¬Å" NP 15.40 4.7 18.40 133/73 114 97% à ¢Ã¢â‚¬  Ã¢â‚¬Å" RA 21.15 6.2 23.05 151/82 119 2 03.15 143/81 106 06.00 6.3 08.30 119/67 94 100% 10.35 4.8 11.24 100/61 107 97% 15.20 112/82 100 16.30 128/70 100 6.2 22.00 3.6 23.50 118/59 66 98%à ¢Ã¢â‚¬  Ã¢â‚¬Å"3L O2 3 04.10 124/64 104 100%à ¢Ã¢â‚¬  Ã¢â‚¬Å"3L O2 06.15 8.2 09.40 100/60 96 11.50 8.5 15.30 108/67 94 17.20 7.4 20.00 121/75 86 4 04.00 110/56 62 06.00 7.9 08.00 110/70 63 4.2 16.00 105/75 91 96% 17.00 9.7 22.00 138/67 114 6.1 5 05.00 9.6 07.15 11.1 Pharmaceutical Care Issues The first care issue is to review the management of AEBA based on the British Guideline on the Management of Asthma. The dose of prednisolone should be increased to 50mg once a day for at least 5 days or until recovery. Since the patient is prescribed with theophylline on discharge, she should be counseled on the signs and symptoms of theophylline toxicity such as confusion, dizziness, diarrhoea, nausea, fatigue and headache. The second issue is regarding the choice of antibiotics for the treatment of community acquired pneumonia in this patient. A sputum full examination microscopic examination (FEME) should be requested to identify the causative microorganisms of the lung infection. If empirical treatment is to be started the preferred drugs of choice would be amoxicillin 500mg three times a day plus either erythromycin 500mg four times a day or clarithromycin 500mg twice daily. Alternative choices would be levofloxacin 500mg once daily or moxifloxacin 400mg once a day, should the patient be intolerant of the preferred regimen. Thirdly, there is no clear indication of the prescription of the diphenhydramine in the first place, as it would only suppress the patients cough, which is inappropriate. Hence it should be stopped immediately. Next, the patients updated blood cholesterol levels should be taken and the appropriate use of statins should be reviewed. As she is on long-term statin use, her liver enzymes should be monitored regularly and if is raised by three-fold, she should stop taking the Lovastatin. She should also be counseled on the symptoms of rhabdomyolysis which is related to the long term use of statins, such as unexplained muscle pain, stiffness, weakness and the darkening of urine colour. The following issue is regarding the patients diabetes management. A HbA1c test should be done to determine her glycated haemoglobin level to see how well her self-management has been. She should also be advised on diet and lifestyle to keep her diabetes under control. Lastly, as she has low red blood count, haemoglobin and haematocrit levels, it is suspected that she has anaemia. Further tests should be done to confirm this, and if it is diagnosed, she should be given ferrous supplements such as ferrous sulphate tablets 200mg twice daily. DISEASE OVERVIEW AND PHARMACOLOGICAL BASIS OF DRUG THERAPY Acute Exacerbation of Bronchial Asthma: An Overview Asthma is a chronic inflammatory disorder of the airways where many cells and cellular elements play a role. This leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the morning. These inflammatory symptoms are commonly associated with extensive but variable airflow obstruction within the lung as well as airway hyperresponsiveness and this is reversible either on its own or with treatment. 1 Asthma is a worldwide problem as it is estimated that about 4.5% of the worlds population is affected, which amounts to 300million individuals approximately. The global prevalence of asthma varies from 1-18% of populations in countries all over the world. Asthma has three distinguishing characteristics which are airflow limitation, airway hyperresponsiveness, and bronchial inflammation. Airflow limitation is usually resolved by itself with or without treatment but for individuals with chronic asthma, inflammation may result in irreversible airflow limitation. Stimuli such as irritants or allergens may pose as triggers in airway hyperresponsiveness and bronchial inflammation is associated with eosinophils, T-lymphocytes and mast cells which cause plasma exudation, smooth muscle hypertrophy, mucous plugging and epithelial changes. It is shown that inflammation of the airways play a major role in the pathology of asthma and this starts when allergens or irritant trigger the activation of cells such as epithelial cells, macrophages, lymphocytes and mast cells. This leads to cytokine or mediator release and smooth muscle contraction resulting in cellular infiltration of eosinophils and neutrophils causing airway inflammation including oede ma, epithelial permeability or injury, mucous secretion and vascular permeability which eventually leads to airway obstruction and hyperresponsiveness. The diagnosis of asthma is based on a collection of signs and symptoms without a reasonable explanation for them and spirometry is an early test which is easy to assess if there is any airflow obstruction present and its extent. For diagnosed patients with asthma, acute exacerbations may occur and because patients with severe asthma are at increased risk of death following exacerbations, assessments of exacerbations are crucial. Clinical features of acute asthma exacerbations include severe breathlessness, tachypnoea, tachycardia, silent chest, cyanosis, or syncope. Peak Expiratory Flow (PEF) or Forced Expiratory Volume in one second (FEV1) is also used to measure the lung capacity. Oxygen saturation (SpO2) is measured using a pulse oximetry and this aids oxygen therapy as oxygen therapy is given in order to keep SpO2 levels at 94-98%. Measurements of arterial blood gases (ABG) are usually not necessary unless patients present with features of life-threatening asthma or have SpO2 of less than 92% as there may be a risk of hypercapnea if SpO2 is lower than 92%. Chest X-rays are also not recommended unless patients are suspected of pneumonia or lung consolidations, suffering from life-threatening asthma, having unsatisfactory response to treatment or if they require ventilation. Pharmacological Intervention in the management of AEBA2 Oxygen Oxygen therapy is needed most of the time as patients who are having acute asthma usually present with hypoxia as well. Hence, all patients with hypoxia who are suffering from acute severe asthma should be given oxygen and their SpO2 levels should be kept at 94-98%. ÃŽÂ ²2 agonist bronchodilators As first line therapy, high dose inhaled ÃŽÂ ²2 agonist bronchodilators are used as soon as possible as rapid relievers of bronchospasm. For patients who are unable to use inhaled therapy, intravenous ÃŽÂ ²2-agonists are used instead. ÃŽÂ ²2 agonist bronchodilators work by stimulating the ÃŽÂ ²2 adrenoceptors in the lungs, thus causing relaxation of the airways. Examples of short acting ÃŽÂ ²2-agonist are salbutamol and terbutaline, and a long acting ÃŽÂ ²2-agonist is salmeterol. Glucocorticosteroids Steroids should always be given in all cases of acute asthma. Examples of these are prednisone, prednisolone, dexamethasone, and hydrocortisone. They exert an anti-inflammatory effect by inhibiting transcription of the genes for the cytokines implicated in asthmatic inflammation and hence reduce airway hyper-responsiveness. Anti-cholinergic agents Ipratropium bromide is one of the anti-cholinergic agents that is used widely in treatment of acute exacerbations of asthma. Nebulised ipratropium bromide is used in combination with a ÃŽÂ ²2-agonist bronchodilator as treatment for patients with severe acute or life-threatening asthma. Anti-cholinergic agents work by inhibit muscarinic receptors M1 and M3 which then reduces cGMP formation and decreases smooth muscle contractility in the lungs. This eventually results in bronchodilation and reduces mucus secretion. Other therapies Other therapies include the use of magnesium sulphate. A single bolus dose of intravenous magnesium sulphate is administered to patients with acute severe asthma with previous unsatisfactory response to inhaled bronchodilator therapy or for patients who are suffering from life-threatening or near fatal asthma. It is believed that magnesium sulphate works by reducing calcium uptake by the bronchial smooth muscle cells, causing bronchodilation and also inhibits mast cells degranulation, thus reducing the release of inflammatory mediators such as histamines, and leukotrienes. EVIDENCE FOR TREATMENT OF THE CONDITION The management of asthma can be divided into two parts; acute treatment, and long term management. Management of acute asthma It has been shown that most patients suffering from acute severe asthma are hypoxaemic. Therefore it is essential that supplementary oxygen therapy be given to them.3-6 This is administered via a face mask or nasal prong with the patients SpO2 kept between 94-98%.7 Where nebulisers are needed in therapy, oxygen-driven nebulisers are favoured instead of those that are air-driven due to oxygen desaturation when driven by air alone.8-10 However, the lack of provision of supplemental oxygen should not pose as a factor in omitting nebulised therapy from administration if deemed appropriate.11 Referring to the case presented above, the patient was treated accordingly as she was immediately given supplemental oxygen and her SpO2 was maintained well above 96% throughout hospital stay. As acute asthma is associated with symptoms of bronchospasms such as wheezing and tachypnoea, the main aim of treatment is to quickly resolve these symptoms and most often, high doses of inhaled ÃŽÂ ²2 agonist bronchodilators are effective with minimum adverse effects.12-14 Salbutamol is usually the drug of choice although there is no significant differences in terms of efficacy as compared to Terbutaline. It is shown that there are no significant clinical benefits by using a non-selective ÃŽÂ ²2 agonist such as epinephrine instead of selective ÃŽÂ ²2 agonists.15 Based on a meta-analysis, it is seen that ÃŽÂ ²2 agonists administered via inhalation are more preferable and has similar efficacy with those administered intravenously in adult acute asthma.16 In ventilated patients or those in life-threatening conditions, parenteral ÃŽÂ ²2 agonists may be added to inhaled ÃŽÂ ²2 agonist treatment although there is little evidence supporting this treatment. Although a sing le bolus nebulisation may relieve most acute asthma cases, it is shown that continuous nebulised treatment of ÃŽÂ ²2 agonists is more effective in relieving acute asthma for those with unsatisfactory response to initial therapy.17, 18 Steroid therapy is always given in acute exacerbations of asthma and it is proven that it has better result if given earlier. It not only reduces mortality but it also reduces relapses and the number of hospital admissions as well.19, 20 Oral steroids given are seen to be equally as effective as parenteral treatment hence there is no need for the use of parenteral administration of steroids unless the patient is unable to tolerate orally.19 Prednisolone 40-50mg is given daily for at least five days or until recovery and this can be stopped abruptly after the patient has recovered.2 As long as the patient is on inhaled steroids, there is no need for the dose to be tapered down slowly prior to discontinuation.21 In the case presented, the patient was commenced on steroid therapy but was under-treated as she was only given prednisolone 30mg once daily for just one day. Hence, there is a need to increase the dose of prednisolone to 50mg and to continue is for at least another four days or until recovery before stopping this treatment. In hospital therapy, anticholinergic treatments are given to severe exacerbations of asthma and nebulised ipratropium bromide is always the drug of choice used in clinical settings. A combination of nebulised ipratropum bromide with a ÃŽÂ ²2 agonist bronchodilator is often given as treatment as it is proven that a combination of these two agents has a significant increase in bronchodilatation as compared to the use of a ÃŽÂ ²2 agonist alone. Hence, there is faster recovery and will reduce the length of hospital stay. However, it is also seen that anticholinergic treatment is not particularly effective and favourable for cases of mild exacerbations of asthma as well as after the patient has been stabilized, thus is not necessary in these cases.22-24 The patient in this case was seen to be having a mild exacerbation of acute asthma and hence nebulised ipratropium bromide treatment was not necessary. However, the use of nebulised Combivent, a combination of ipratropium bromide and salbutamol was justified since this patient was re-attending with a relapse and she was also suffering from pneumonia as well. Hence, there was probably a need for a quicker rate of bronchodilation as well as faster recovery for her. The use of magnesium sulphate in hospital treatment of AEBA is not widely seen, however there have been some evidence showing the bronchodilating effects of magnesium sulphate when used in adults.25 There are also studies which report that nebulised magnesium sulphate combined with a ÃŽÂ ²2 agonist shows positive outcomes and good clinical effectiveness in hospital settings.26, 27 The use of an intravenous bolus administration of magnesium sulphate is believed to promote lung function in patients who have severe asthma without harmful side effects.28 Nevertheless, there have been no studies on the repeated administrations of magnesium sulphate, though it is presumed that repeated use may lead to hypermagnesaemia, causing muscle weakness and respiratory failure. As further extensive studies need to be done to determine the most suitable route and dosing of magnesium sulphate, this treatment is reserved only for patients with acute severe asthma without satisfactory response to inha led bronchodilator therapy and patients with life-threatening of near fatal asthma. Monitoring should be carried out constantly throughout hospital stay and in acute asthma cases, monitoring of PEF is crucial. PEF readings should be measured and recorded every 30 minutes after treatment has been started. PEF should also be monitored pre- and post- nebulisation therapies as long as the patient is in hospital and until the asthma is well under control after discharge. It is seen that after hospital discharge, a relative amount of patients either experience relapse or are readmitted into the hospital with at least 15% within two weeks following discharge.29 Therefore it is essential that patient education such as proper inhaler technique, and well-documented PEF recordings with action plans depending on symptoms experienced should be instilled in order to reduce rate of relapses as well as minimize problems associated with exacerbations after discharge.30 Monitoring of the patients PEF was done consistently throughout her hospital stay and the patient was given sufficient counseling prior to discharge on her inhaler technique. However, there was no evidence that the patient was educated on self-documenting PEF recordings as well as action plans based on symptoms experienced following discharge and this should be done in this case to avoid another exacerbation of her condition. Long Term Management of Asthma The aim of management of asthma is to keep it well-controlled without the need of rescue medications, asymptomatic, no exacerbations, no hindrance to daily activities including exercise as well as normal lung function. A stepwise management approach is adopted for asthma patients and this is to acquire initial control and maintain it by stepping up treatment to improve control if necessary or stepping down treatment if there is good control over the condition to maintain the lowest step that will control the patients condition. As the patient is currently on regular preventer therapy with inhaled steroids, she is currently on step 2 of the management of asthma. There have been many studies being carried out to compare the different inhaled steroids that are being used for asthma and it is shown that beclomethasone diproprionate and budesonide are both similarly clinically effective although there may be different devices for delivery. It has also been seen that fluticasone and mometasone being administered at half the dosage of beclomethasone and budesonide shows equivalent clinical effectiveness, however there is somewhat inadequate evidence that fluticasone possesses fewer side effects and further studies need to be carried out on establishing the safety profile of mometasone.31 A new inhaled steroid has been introduced which is ciclesonide and clinical trials have shown evidence that it has more local activity than systemic and less oropharyngeal side effects as compared to the regular inhaled steroids.3 2-35 Although this seems promising, this clinical advantage is still controversial as its safety to efficacy ratio has yet to be established and compared with the conventional inhaled steroids. Inhaled steroids are recommended as preventer drug therapy for adults as they are most clinically effective in controlling asthma based on the treatment goals outlined.36-39 The frequency of dosing of inhaled steroids are generally twice daily and it is shown that there is slight clinical benefit obtained when taken twice a day than once daily, however a once daily dosing may suffice for those with milder asthma. There is also limited evidence of advantage with increased frequency of greater than twice a day.37 In addition to that, starting at higher than recommended doses have no significant effectiveness in management of mild to moderate asthma.40 Hence the recommended dosage for inhaled steroids would be 200-800mcg daily. This would be an add-on therapy to the step 1 management of using in haled short acting ÃŽÂ ²2 agonist bronchodilator as required. Based on the presented case, the patient was on budesonide 200mcg once at night prior to admission but this was immediately increased on admission and was in line with the recommended guidelines as she was continued on budesonide 400mcg twice a day together with salbutamol 200mcg as required following discharge. Other preventer therapies may be included for the patient despite inhaled steroids being the first choice of drugs for preventer therapy. These alternatives are less effective although they have shown some clinical benefit in patients who are on short acting ÃŽÂ ²2 agonists only. Chromones which act as mast cell stabilizers such as sodium cromoglicate and nedocromil sodium have shown to be beneficial in adults.41, 42 Apart from that, leukotriene receptor antagonists montelukast and zafirlukast too have clinical benefits.37, 43, 44 Theophylline also have some evidence in showing benefits in adults.36, 45 The patient in the case presented above was prescribed sustained-release theophylline on the last day of admission. Although it is another option that may be added to daily controller medications for step 2 management, there is very little evidence on the clinical efficacy of it as a long term controller. There is no reason to justify the use of theophylline in this case as the patient is responsive and can be controlled on inhaled steroids. Further more, theophylline has a narrow therapeutic index and close monitoring of plasma theophylline levels is necessary because at concentrations above 25 µg/ml, there is high risk of tachycardia and seizures may occur if concentrations exceed 35 µg/ml. CONCLUSION After reviewing the management of the patients condition throughout hospital stay, it can be concluded that SK was treated adequately based on the current guidelines and evidences attainable. She was given all necessary treatment at point of admission and there was no lacking of medications in all four days of her hospital admission. Apart from that, monitoring of her condition was carried out consistently and all data was updated, leaving no room for questioning and doubt. However, there were a few issues that came to attention which were the prescribing of several drugs that were unnecessary such as diphenhydramine and theophylline. There were little and no clear evidence that these drugs prescribed would be of benefit to the patient, and may also increase the risk of harmful effects to her as well. Alongside treatment of her acute condition, SKs controller medications were reviewed and subsequent changes were made as appropriate. Besides that, her other co-morbidities were also managed well as treatments for her hypertension and diabetes mellitus were given accordingly. PATIENT MEDICATION PROFILE PATIENT DETAILS Name S.K. Consultant Dr YKS General Practitioner Address Gender Female Weight 65kg Height 1.59m Community Pharmacist Date of Birth (Age) 54 years old Known Sensitivities NKDA Social History Widow of 6 years, Housewife, Non-smoker, Does not drink PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date 17/04/09 Shortness of breath for the past two days, progressively Discharge Date Discharged to 21/04/09 Home worsening today and productive cough. RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments 2001 Diabetes Mellitus T. Diamicron 80mg BD 2001 Hypertension T. Metformin 500mg TDS 2004 Gastritis T. Telmisartan 40mg ON 2009 Bronchial Asthma MDI Salbutamol 200mcg PRN MDI Budesonide 200mcg ON T. Lovastatin 20mg ON RELEVANT NON DRUG TREATMENT Prescribed Medication Start Stop Clinical/Laboratory Tests Date Result 1 T. Telmisartan 40mg OD 18/04 21/04 2 T. Gliclazide 80mg BD 17/04 17/04 3 T. Metformin 500mg TDS 17/04 4 T. Lovastatin 20mg ON 17/04 19/04 5 MDI Salbutamol 200mcg 2 puffs PRN 17/04 6 MDI Budesonide 200mcg 2 puffs BD 17/04 7 T. Prednisolone 30mg OD 17/04 17/04 8 Neb. Combivent 6-hourly 17/04 19/04 9 IV Ceftazidime 2g STAT, then 1g TDS 17/04 21/04 10 S/C Humulin R 10units TDS 17/04 21/04 11 S/C Humulin N 12units ON 17/04 21/04 12 Syrup Diphenhydramine 15mls TDS 18/04 20/04 13 T. Slow K 2tabs BD 18/04 20/04 14 Mist KCl 15mls TDS 18/04 20/04 15 T. Theophylline 250mg OD 20/04 CLINCIAL MANAGEMENT Diagn

Intelligence LED Policing (ILP) Essay

In the U. S. policing the ILP application has faced various challenges that has led to the complication of the policing model. On top of the 9/11 stimulation, the move towards ILP has been advanced by various initiatives of the public policy. Therefore, due to the varied demands, ILP has been integrated with community policing so as to achieve these new standards. Though widely used by the police services, ILP clarity in its definition and elementary conceptions has hardly been understood. ILP uses the intelligence from covert information as a resource for strategic planning rather than as a way of budding specific evidence for a case. It puts more emphasis on crime intelligence and data analysis in making decisions that smooth the progress of problem and crime reduction, distraction and preclusion by means of strategic management and enforcements strategies that are effective on inexhaustible and somber offenders and criminal groups. Moreover, through crime intelligence analysis, ILP identifies the criminal offenders as threats via a top-down approach that is managerially steered. Through this approach, is also deals with issues of public trust without necessarily involving crime control elucidation (Ratcliffe, 2008). In preventing past misconducts, this model organises a Compstat along the administrative units of the police to effect the changes. Through these Compstat meetings, crime patterns that occurred in the past are reviewed. In the review, commanders identify the hot spot for crime and disorder through crime analysis and necessary action is taken by the police officers. The combination of crime intelligence and crime analysis help direct the police resource decisions more objectively through prioritisation. In addition, the prevention of past crimes in achieved through the utilisation of the three i-models between the decision maker, crime intelligence analysis and the criminal environment. This model is made up of interpret, influence and impact. The decision makers have to bring impact to the criminal environment, the analysts for crime intelligence interpret this environment with intelligence to influence the decision makers (Ratcliffe, 2008).

Factors influencing child development Essay

1.0 introduction In the study of development, nurture is defined as the environmental conditions that influence a child’s development (T. M McDevitt and J. E. Ormrod , 2010). A child’s home environment, friends with whom he spends time with, the food that he eats and the types of movies he watches — not to mention the content and or education background – are all the factors that influence his physical, social and cognitive development in both positive and negative perspective. In this paper, I will be focusing on nurture factors and how do these factors have influenced the development of the prominent figures that I have chosen which are Tun Dr. Mahathir, our very own 4th Prime Minister from Malaysia and Bill Gates, the billionaire, from United States of America. The development that I will be touching on is regarding the physical development, cognitive development as well as the language development. Read more:  Explain how children and young people’s development is influenced by a range of external factors essay 2.0 Tun Dr. Mahathir Tun Dr. Mahathir was the 4th Prime Minister of Malaysia. He is fondly known as the â€Å"Father of Modern Malaysia†. He was born on the 10th July 1925 in Seberang Perak, Alor Setar, Malaysia, but his father, Mr Mohamed B. Iskandar, only registered his date of birth on 20th December 1925. His mother’s name is Wan Mas Tempawan Bt Wan Hanafi. He is the youngest in the family and is very close to his five brothers and sisters. He got married with Tun Dr Siti Hasmah Bt Haji Mohamed Ali on 5th August 1956 and were given seven children. After I went through Tun’s background, there are two nurture factors that contributed to his development. The nurture factors are as follow: 2 2.1 Nurture factors 2.1.1 Family Family has always become the priority in an individual’s life. In my humble opinion, every success of a man lies on their family supports and values. This statement is agreed by Tun Dr. Mahathir himself whereby he believes in  family values and close family relationship (Fam, Lee, Nawarmani Balakrishnan and R. Rajendran, 2006). During his childhood, Tun and his siblings were taught to behave with discipline in everything that they do (Mahathir, 2011). His father, Mr Mohamad B. Iskandar, is the first Malay Headmaster of the Government English School in Alor Setar. Whenever Tun Dr Mahathir and his siblings came back from school, their father would go through their homework with them. Even during the holidays, their father would sit down with them, patiently tutoring them and setting a timetable for them to do reading, school work etc. He would teach them the way that he taught his students in school. Apart from that, Tun and his siblings lived in awe of their father even though he never laid a hand on them. This is because the sound of their father’s cough was enough to send them scurrying back to their books and homework (Mahathir, 2011). They all studied at the big table in the front room and will only stop for dinner. It is such discipline that Tun Dr Mahathir grew up to be a well-mannered and educated man with good values. Thus, I would say that family plays a very important role to develop a child’s cognitive development. In fact, family is the biggest influence during childhood, as the children view their parents as their role models. 3 2.1.2 Education Besides family, education also plays a vital role in the development of Tun Dr. Mahathir. Despite the informal education that he got from his own family, he also went to school to get his early education. He started schooling when he was 5 years old in a Malay School in Jalan Seberang Perak. He has the determination of wanted to have a better education than what most Malays had at that time. For that, he went to English School and passed his examination. At school, the students were not allowed to speak any languages other than English language. So with such practice, Tun Dr Mahathir developed his language development and is able to converse English language fluently. All these happened during his primary school days. After he finished his primary school, he then went to Sultan Abdul Hamid College to do his secondary education. However, during that time, the Second World War started. As a result, it was difficult for him to study and he decided to  seek for a job. So, he started his business mind and thought of something to sell. Together with his two friends, he set up a stall selling coffee and ‘Kuih’ (Malaysian cakes). He made a good business with the stall and soon was able to sell the stall for a good sum of money. This matter showed he has a good acute business sense. After selling the stall, he moved to a better location at a small complex. He then thought of selling fried bananas. He made money selling the fried bananas and also made many friends. This incident proves that, at a very young age, he is able to think, strategize, and find solution for any problems that occur. 4 Indirectly saying, Tun was exposed to cognitive skills through his own experiences not only from education but also from the business perspective. In 1945, after the Second World War ended, Tun Dr Mahathir resumed his education at Sultan Abdul Hamid College where he sat for and passed his Cambridge Examination. He did a lot of reading on political issues in his father’s huge library in school. He gained a lot of information from his reading. From here, it is proven that Tun also developed his cognitive skills by reading books especially in political issues. In school, joining extra-curricular activities was part of the system. Therefore, Tun joined the rugby club although he was not very interested in games and sports but then he found out that he quite enjoyed playing rugby (Fam, Lee, Nawarmani Balakrishnan and R. Rajendran, 2006). From here, I would say that school activities play a significant role in shaping Tun physical development such as grass motor skills, which includes running. Finally, in the year 1947, after he had gone through much experience in working, he then continued his tertiary education in medical field at the King Edward VII Medical College, Singapore. With all the skills that he got from early of his primary school up to secondary school and working experiences, I do not think Tun will face a problem in his studies especially when it comes to speaking skills and finding solution to any problems. 5 3.0 Bill Gates The way Bill Gates was brought up is different from Tun Dr. Mahathir. Unlike  Tun, his education plays a significant role in shaping his development. In contrast, after I went through Bill Gates’s biography, I found out that it is his peers that have influenced his success. He and his partner, Paul Allen, built the world’s largest software business called Microsoft. In the process, Gates became one of the richest men in the world (The Biography Channel Website, 2004). There are two nurture factors that contributed to his development. The nurture factors are as follow: 6 3.1 Nurture Factors 3.1.1 Family Bill Gates was born on 28th October 1955, in Seattle, Washington, United States of America. His real name is William Henry Gates III. His father’s name is William Henry II who works as an attorney and his mother’s name is Mary Maxwell, who works as a teacher. Bill gates grew up in an upper middle-class family with two sisters: Kristianne and Lubby (The Biography Channel Website, 2004). The Gates family atmosphere was warm and close and all three children were encouraged to be competitive and strive for excellence. It is such discipline that made him a very competitive person. For example, Bill showed early signs of competitiveness when he coordinated family athletic games at their summer house on Puget Sound (The Biography Channel Website, 2004). Bill Gates was a voracious reader when he was a child (The Biography Channel Website, 2004). He would spend most of his time by looking for information in reference books such as encyclopaedia. Gates weird behaviour made his parents more concerned of his academic achievement. Thus, he was sent to Seattle’s Lakeside School. As a result, at age 13, he blossomed in nearly all the subjects and also doing very well in drama. At a very young age, his cognitive development was trained by his family. Thus, by that kind of environment – competitive among his siblings, excel in academic field – has made him become one of the most influential persons in the globe. 7 3.1.2 Peers As I mentioned earlier, Bill Gates and his business partner, Paul Allen, both shared the same interest over computers. It is through peers that Gates  slowly developed his cognitive skills in computer field. It all started when both of them eventually met in high school when their school offered computer class for the students. Although the two were very different in their personality – Bill was feisty and combative, in contrast, Allen was more reserved and shy (The Biography Channel Website, 2004). But all in all, I believe, with such differences that have made them a good companion. At the age of 15, Bill and Allen went into business by creating â€Å"Traf-o-Data†, a computer program that monitored traffic patterns in Seattle. Believe it or not, their efforts had made a total profit of $20,000. Another big project that they had worked together was with Micro Instrumentation and Telemetry Systems (MITS). Both of them worked days and nights until they got hired by the company. Until in the year 1975, Gates and Allen formed a partnership. This partnership was called Micro-Soft, a blend of â€Å"micro-computer† and â€Å"software†. In a child’s development, peers play a vital role in shaping any abilities or talents that a child has (Barnes. S, 2014). As for Bill Gates case, he enjoyed making friend with Paul Allen because both of them shared the same interest over computer. Plus, their interest does not even affect their achievement in academic. In fact, Bill Gates excelled in his studies. 8 4.0 Conclusion In brief, after I went through both the prominent figures’ biography, I found out that the nurture factors of a child comes hand in hand with physical development, cognitive development as well as language development . Due to the fact that both the prominent figures differ from the way they have been brought up, it is clearly evident that nurture factors do play a vital role in their development. One of the biggest nurture factors in a child’s development, I would say, is family. In social studies, family is one and the most important agents of socialization (Macionis, J.J., 2012). Through the teaching, support, surroundings and values that the family have, it will somehow and eventually determine a child development. If the family have a good background – despite the parents’ academic achievement, enough nutrition being given by the parents, etc – indirectly, a child will face zero problems in any aspects of their development. 9 REFERENCES Barnes. S. (2014). Peer Relationships, Protective Factors, and Social Skill Development in Low- Income Children. Retrieved from, http://steinhardt.nyu.edu/opus/issues/2013/fall/barnes, on April, 2014. Bill Gates (2014). The Biography Channel website. Retrieved 06:35, Apr 1, 2014, from http://www.biography.com/people/bill-gates-9307520. Joan Fam L. H, Lee, Nawarmani Balakrishnan & R. Rajendran (2006). Tun Dr. Mahathir’s legacy: An inspirational learning experience. Kuala Lumpur: Krista Education Sdn Bhd. Macionis. J. J. (2012). Sociology. United States of America: Pearson Education, Inc. Mahathir Bin Mohamad (2011). A Doctor in the House: The Memoirs of Tun Mahathir Muhamad. Selangor : MPH Group Publishing Sdn.Bhd. T. M McDevitt &J. E. Ormrod (2010). Nature and nurture. Retrieved, April 3, 2014, from http://www.education.com/reference/article/nature-nurture/

Internet Essay - Online Anonymity and Cyberspace Crime

Online Anonymity and Cyberspace Crime The 90s internet boom gave rise to new ways of writing in through access to cyberspace. What used to be printed or handwritten on physical surfaces such as paper, cardboard, or bulletin boards has changed to 0s and 1s, bits and bytes of digitized information that can be displayed thru the projections of computer screens. Moreover, the internet has made the process of publishing ones works, writing letters, or chatting with one another much easier and convenient for everyone around the globe. The internet became a universal tool, giving much freedom and flexibility to the users; it gave them opportunity to deliver their thoughts with little or no restrictions. Since its impossible to regulate†¦show more content†¦Hence, the sender stays completely anonymous. Moreover, use of pseudonyms made it possible for anyone to simply wander around the cyberspace without being identified as a real person with a real identity. Since a persons existence in cyberspace is not physical, any p erson can take on a desired personae and become a person A in one chatting channel and at the same time take on the different personae of B or C in different zones. People rarely use pseudonyms in real life; actors, actress, and many public figures take on pseudonyms not because they intentionally want to hide their real names, but to enhance their public image. However, pseudonyms are almost always used by the net users, and it becomes problematic when they intentionally fake their gender, ethnicity, age, and other personal information in order to take advantage of other people. Anonymity and pseudonymity can be beneficial to certain parts of the internet community. One example can be seen in a web-based public forum, where anyone can freely join and take on either side of the argument and express his or ideas without having to worry about receiving physical accusations, reprimands, or revenge from the opposing side: FreeShow MoreRelatedEssay on Social Harm Can Help Us to Explore the Complexities of2020 Words   |  9 Pagesthe complexities of ‘crime’. Introduction: The concept of crime differs widely between nations and within different social groups, locally and globally. The influence of governments, corporations and individuals who are able to wield power enables differing concepts of crime to flourish, and the interpretation of crime to vary according to laws implemented by those in power. Criminal justice also varies within different nation states. In exploring the complexities of crime it is important toRead MoreEssay on The Dark Side of the Internet1018 Words   |  5 PagesAs the internet has evolved, it is now a part of most people’s daily lives and with that, the populate could not function or conduct their daily business or activities without it. Impressive, we can now communicate and even see someone all the way across the country with just a few clicks of a mouse. But as technology changes and progresses seemingly for the good, as always people will find ways to exploit technology and use it with the intent of committing crimes and turning a positive tool intoRead MoreThe Internet-a Curse, Not a Blessing1519 Words   |  7 Pages‘The Internet- a curse, not a blessing.’ Beyond a shadow of a doubt, the invention of the Internet is one of man’s greatest and most spectacular endeavours. For, it has truly revolutionalized the world in regards to how we engage in business, recreate, socialize, educate ourselves and communicate with each other. The Internet eliminated all impediments of conventional methods of operations. Through its construction, the world economies have flourished. Therefore, it can be said in a nut shellRead MoreEssay about Wikileaks and Julian Assange3373 Words   |  14 Pages Zetter, 2010) Introduction In his article, The Mediatisation of Society Theory, Hjarvard (2008) deduces that media simultaneously become an integrated part of society, not to mention the existence of new media like the Internet. In fact, this integration of Internet into our daily life has made us live in the digital age where information is shared in real time and in global context. Castells (2007) even argues that in this digital age, people are able to expand their local communication activitiesRead MoreThe Issue Of Hate Speech Promulgated Through The Internet2667 Words   |  11 Pagespromulgated through the internet poses a significant problem for the traditional legal system. The anonymity and mobility of the Internet has made harassment and expressions of hate reach far beyond boundaries of traditional law enforcement. However one must be careful when dealing with such complex offences, ensuring that they are interpreted in a manner that places a balance between what is considered a crime against another and what is considered free expression of views. In this essay I will be examiningRead MoreHow Identity Theft Affect the Culture of Our Society5785 Words   |  24 Pagesperhaps prevented, like the single mother, it will be neither a quick or easy one to fix or prevent. Identity theft affects millions of Americans in various forms every day. It is one of the fastest growing crimes in the United States and is increasingly affecting consumers’ online transactions. Scam artists and hackers lay in wait for an unsuspecting person to get caught in up their scheme through ignorance or naivety so they can take full advantage and gain access of their personal informationRead MoreFundamentals of Hrm263904 Words   |  1056 PagesThis online teaching and learning environment integrates the entire digital textbook with the most effective instructor and student resources With WileyPLUS: Students achieve concept mastery in a rich, structured environment that’s available 24/7 Instructors personalize and manage their course more effectively with assessment, assignments, grade tracking, and more manage time better study smarter save money From multiple study paths, to self-assessment, to a wealth of interactive visualRead MoreLibrary Management204752 Words   |  820 PagesPhysical Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Job-Related Mental Stress . . . . . . . . . . . . . . . . . . . . . . 276 Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Violence and Crime in the Workplace . . . . . . . . . . . . . 280 External Impacts on Human Resources—Legal Protections . . . . . . . . . . . . . . . . . . . 282 Equal Employment Opportunities . . . . . . . . . . . . . . . . 283 The Civil Rights Act of 1964 and Other