Case summary and examination of Obstetrics Posting

Case summary and examination of Obstetrics Posting Madam NTR is a 34 years old Malay lady with gravida 4 and parity 3, currently at 37 weeks of gestations. She was admitted on 21st Nov 2010 at gestational age of 30 weeks and 1 day, due to referral from Health Clinic Sendayan in view of placenta previa based on ultrasound findings during a routine antenatal visit. Her estimated date of delivery was on 20th Jan 2011. She was asymptomatic with no complaints of per vaginal bleeding, contraction pain, leaking liquor or show. Fetal movements were felt and were not reduced. She has no history of placenta previa in her previous pregnancies. The first day of her last normal menstrual period was on 15th Apr 2010. This was an unexpected pregnancy but both her and her husband wanted it. She suspected she was pregnant when she missed her menses for 4 weeks. She confirmed her pregnancy after urine pregnancy test done in a private clinic yielded positive result. Booking was done in Maternal and Child Health Clinic Gadong at 16 weeks of gestation and the dating scan at 16 weeks revealed parameters corresponding to date. However, placenta was noted to be low lying during that scan. Throughout her routine antenatal visits, she was normotensive, not anaemic and did not have diabetes mellitus. HIV and VDRL test were negative. Her blood group type is O Rh D  positive. This is her fourth pregnancy. Her third pregnancy was in the year of 2007. She delivered a full term baby boy with birth weight of 2.6 kg via caesarean delivery due to breech presentation in Hospital Tuanku Jaafar Seremban. She delivered her first two children who are both males in the year of 2004 and 2005 via spontaneous vaginal delivery, with birth weight of 4.26kg and 2.6kg respectively. There was no history of shoulder dystocia. All her children were born alive and well. Antenatal, natal and postnatal for all previous pregnancies were uneventful. She attained menarche at the age of 12. It is regular at 28 to 30 days cycle with duration of 5 to 7 days. There was neither dysmenorrhea nor menorrhagia. She practised coitus interuptus as contraceptive measure. She never had any PAP smear done previously. Past surgical, medical and drug history were unremarkable. Family history was unremarkable. She and her husband are married for 7 years. They are staying together with their three children in Gadong Jaya Village. She is a housewife. She neither smokes nor drinks alcohol. On the other hand, her husband works as a construction worker. He is a smoker but not alcoholic. Family income is approximately RM2000 per month which is barely adequate for their living. Physical examination: Madam NTR was alert, conscious and communicative. She was not in pain or respiratory distress. Her height and weight are 165cm and 76kg respectively. Her blood pressure was 110/80 mmHg; pulse rate was 86 beats per minute of regular rhythm and strong volume; temperature was 37 ° C; respiratory rate was 19 breaths per minute. All vital signs were within normal range. Upon general examination, there was no conjunctival pallor, sclera jaundice, palmar erythema or peripheral cyanosis. Thyroid glands were not palpable and breast examination was unremarkable. There was bilateral pedal edema up to mid-shin. Cardiopulmonary examination was unremarkable. Upon examination of the abdomen, it was distended with a gravid uterus. Linea nigra and striae gravidarum were visible. There was a tranverse scar, measuring 12cm, located above pubic symphysis. Distension appeared to be corresponding to gestational age. The umbilicus was flattened. On light palpation, the abdomen was soft and non-tender. Uterus was not irritable. Symphysiofundal height was 38 cm which was corresponding to gestational age. It was a singleton pregnancy with transverse lie and cephalic presentation. The liquor was adequate. Estimated fetal weight was 3.0-3.2kg. Fetal heart sound was 160 beats per minute. Investigations Full Blood Count revealed normal haemoglobin level (10.9g/dL). Transabdominal Sonography(TAS) revealed transverse lie fetus with the presence of fetal activity, estimated fetal weight of 3.19kg at 37 weeks of gestation, anterior placenta previa type 3 (placenta previa major) with evidence of placenta accreta at one area over bladder base.   The images also demonstrated placental lacunae, gross increase in vascularity of cervix which is suggestive of placenta accreta. Diagnosis Anterior placenta previa type 3 with possible placenta accreta. Management Upon admission, Madam NTRs vital signs were taken. Cannula was inserted and blood was taken for full blood count investigation and blood group cross-matching. Madam NTR was also given the explanation to keep her in ward until delivery and the condition of her pregnancy. She was encouraged to rest in bed and decrease activity level to avoid bleeding. Ultrasound was performed to confirm the diagnosis of placenta previa. She was then monitored for any contractions or bleeding. Madam NTRs pad chart, fetal kick chart and labour pregnancy chart were strictly monitored. Fetal heart rate was assessed 4 hourly with Daptone. Cardiotocography was done regularly and it was normal. She was given a course of IM dexamethasone 12mg BD of 1 day duration at 30 weeks of gestation. Full blood count investigation was performed once weekly and transabdominal sonography was carried out once in every 2 weeks throughout admission. Anemia should be corrected if present. Madam NTR was also prescribed ferrous fumarate, folic acid, vitamin B complex as well as ascorbic acid. She was eventually planned for an elective caesarean delivery on 5th Jan 2011 at 37 weeks of gestational age. Prior to that, she was counseled about risk of haemorrhage and possibility of hysterectomy to be done during operation as well as option of conservative management etc. Written informed consent was taken from both her husband and her. Progression Throughout the admission, she was comfortable and her vital signs were all normal. She had no any episodes of vaginal bleed, leaking liquor, show, uterine contraction and pain. She was not anaemic as evidenced by normal values of her haemoglobin levels. The most recent haemoglobin value was 10.9g/dl. Fetal well-being was assured as evidenced by normal CTG results. She and her fetus remained stable until the scheduled operation date. A day prior to that, she was kept nil by mouth. Packed cell blood was ready for transfusion if needed. After delivery of the fetus, manual removal of the placenta was done and placenta accreta was found to be at the anterior bed of lower segment of the uterus. She developed a massive uterine haemorrhage and a hysterectomy was performed. 3 units of packed cells (1 litre in total) were transfused intraoperatively. The operation lasted for 1 hour and 15 minutes. She delivered a baby boy weighs 3.2kg with Apgar score of 6 at first minute and 9 at fifth minute of life. After being assessed by paediatrician, he was discharged to the mother. Estimated blood loss was 2.8 litres. Explanation about intraoperative findings and the decision of attending doctor to proceed to hysterectomy was given to Madam NTR. Postoperatively, she remained hemodynamically stable. Post operative haemoglobin level was 12g/dl. She was able to ambulate and tolerate orally on third day after operation despite minimal pain over operation site. She did not complain of shortness of breath, palpitation, chest pain or calf pain. Baby was pink, active and well with no jaundice. Breastfeeding was established. Both of the mother and baby were discharged on 7th Jan 2011and subsequent follow-up was scheduled to be 2 months later. She should be arranged for psychological review and management as termination of fertility can sometimes cause devastating psychological impact to women. Discussion What other alternatives that Madam NTR has other than hysterectomy in the case of placenta accreta? Is hysterectomy absolutely indicated in Madam NTR? Mainstay traditional management has centred upon hysterectomy which has a high complication rate and terminates fertility of a woman. It can also cause devastating psychological consequences. While in vast majority of cases hysterectomy will remain appropriate, there are other management options available involving conservative approaches. The main nonsurgical conservative management would be to leave the placenta undisturbed in situ for it to be resorbed or to be passed spontaneously. It is expected that bleeding will remain minimal with this approach. This enables fertility to be preserved even though leaving the placenta in situ has implications for infection and recurrence. LoÃÆ' ¯c Sentilhes et al.(1) concludes that  successful conservative management for placenta accreta does not compromise the patients subsequent fertility or obstetrical outcome but there is a high risk that placenta accreta may recur during future pregnancies. Florence  Bretelle et al.(2) conducted a retrospective study in which 50 cases of placenta accreta were studied and 26 patients (52%) were treated conservatively. 21 of them (80.7%) did not undergo hysterectomy and 3 women had successful pregnancy during follow-up. This further proves that treated patient with placenta accreta selectively with conservative approach enables fertility to be preserved without increasing morbidity. However, conservative approach is usually considered only when bleeding is minimal. In this case of Madam NTR, there was severe haemorrhage encountered after delivery of fetus. Conservative management such as leaving the placenta in situ will lead to severe postpartum hemorrhage or even maternal death. Uterine compression suturing to stop the bleeding was not able to be performed as her uterus was too fragile to hold the sutures. Therefore, hysterectomy is absolutely indicated in the case of Madam NTR for her safety. This is her fourth pregnancy; therefore termination of fertility is not a major concern in her as discussed previously prior to obtaining her consent. As Madam NTR was planned for a high risk surgery with possibility of hysterectomy, counseling and obtaining written informed consent prior to surgery play a vital role. After being counseled, Madam NTR stated that she had little understanding about her situation and the surgery but not to the full understanding due to inability to fully comprehend medical terminologies used. The question here would be: Has the attending doctor done his duties well enough and is patients autonomy protected in this context? Informed consent is the core principle of modern medical practice. The primary aim of the consent process is to protect patients autonomy. Patients have the right to refuse medical care, even when it means they will die. This surgery is associated with high complication rate, termination of fertility and devastating psychological consequences to patient. Therefore, educating and informing her about her healthcare options, advantages and disadvantages associated with recommended management as well as other alternatives are very crucial. The point is not merely to disclose information, but to ensure patients comprehension of relevant information. Unfortunately, very often that doctor are disclosing information presuming that patients with different level of maturity, education level, cultural background and native language will be able to comprehend. On top of that, doctors are so used to medical terminologies and it is often found difficult to disclose medical information in laymans terminologies. Majority of patients whom I encounter were not aggressive in seeking opportunities to raise questions to attending doctors, especially during ward round whereby patient will be surrounded by specialist accompanied by medical officers, housemen and medical students. All these further jeopardize patients autonomy to exercise personal choice with total comprehension of relevant medical issues. In the case of Madam NTR, she and her husband should first of all be told what a placenta is before explaining to them about placenta praevia. Subsequently, attending doctor should explain to her the reason vaginal delivery was not able to be carried out as the placenta covers the entrance to the womb (cervix) entirely, which is known as major placenta praevia. Therefore, caesarean delivery is absolutely indicated and it will be conducted by experienced obstetrician and anaesthetist on duty. If an emergency arises, a consultant will be present. Risk of severe bleeding from placenta praevia which can put the life of the mother and baby in danger should be emphasized; therefore explaining the purpose of blood group cross- matching for blood transfusion. She should also be informed that rarely, placenta praevia may be complicated by a problem known as placenta accreta, when the placenta is abnormally attached to the womb, making separation at the time of birth difficult. Most of the time, it will pass out spontaneously. However, if the bleeding continues and cannot be controlled, removing the womb has to be done to control the bleeding after consideration of conservative approaches such as leaving it in situ with possibility of recurrence or infection fails. She has to be told to fast prior to operation. Choices of analgesia should be discussed with anesthesiologist in relation to risks and advantages for each option. Lastly and most importantly is to assure her that the healthcare team will recommend the best way for both her and her baby and at the same time, she has the right to be fully informed about her health care and to share in making decisions about it. Under the law, the doctor has a duty of medical care to give adequate information about the proposed medical treatment. The breach of informed consent in todays legal setting is more commonly interpreted as negligence when the doctor has not disclosed the risk of procedure and when the risk occurs, causing harm to patient. In the English case of Wells v Surrey Area Health Authority (3), a 36-year-old woman with 2 children, was advised to proceed to caesarean delivery after prolonged labour. She was in exhausted state when she was suggested to be sterilized during the surgery and consent was signed and sterilization was done. When she recovered, she complained that consent was invalid as it was taken when she was mentally confused. She sued the doctor for assault and battery for operation was done without consent as well as for negligence as information regarding sterilization was not given at all. In conclusion, informed consent should be practiced in the correct way, especially in obstetrics and gynaecology, an area with high risk of medico-legal perspectives, to provide best treatment and management to patient and fetus as well as protecting doctors from being sued for negligence.

The Return: Shadow Souls Chapter 8

As they hastened from the car to the secluded motel room, Elena had to put pressure on her legs to keep them steady under her. As soon as the door to the room slammed shut, with the storm more or less outside and her own stiff and aching body inside, she headed for the bathroom without even turning on a light. Her clothes and hair and feet were all damp. The fluorescent lights of the bathroom seemed too bright after the darkness of the night and the storm. Or maybe it was the beginning of her learning to circulate her Power. That had certainly been a surprise. Damon hadn't even been touching her, but the shock she had felt still reverberated inside her. And as for the feeling of having her Power manipulated from outside her body, well, there just weren't words. It had been a breathtaking experience, all right. Even now just thinking about it made her knees tremble. But it was more clear than ever that Damon wanted nothing to do with her. Elena confronted her own image in the mirror and winced. Yes, she looked like a drowned rat that had been dragged backward a mile through the gutter. Her hair was damp, turning its silky waves into tiny wisps of curls all around her head and face; she was as white as an invalid, and her blue eyes were staring out of the pinched and exhausted face of a child. For just a moment she remembered being in even worse shape a few days – yes, it was only days – ago, and having Damon treat her with the utmost gentleness, as if her bedraggled appearance had meant nothing to him. But those memories had been taken from Damon by Shinichi, and it was too much to hope that that might have been his real state of mind. It had been†¦whim†¦like all his other whims. Furious at Damon – and at herself for the prickling behind her eyes she felt – Elena turned away from the mirror. The past was the past. She had no idea why Damon had suddenly decided to start jerking away from her touch, or to look at her with the hard cold eyes of a predator. Something had caused him to hate her, to barely be able to sit in the car with her. And whatever it was, Elena had to learn to ignore it, because if Damon left, she would have no chance of finding Stefan. Stefan. At last her trembling heart could find rest in thinking of Stefan. He wouldn't care what she looked like: his sole concern would be for her well-being. Elena shut her eyes as she turned on the hot water in the tub and stripped off her clammy clothes, basking in her imagination of Stefan's love and approval. The motel had provided a small plastic bottle of bubblebath, but Elena left it alone. She'd brought her own translucent-gold bag of vanilla bath crystals in her duffel bag, and this was the first chance she'd had to use it. Carefully, she shook about a third of the beribboned bag's crystals into the rapidly filling tub and was rewarded with a steamy blast of vanilla, which she drew into her lungs gratefully. A few minutes later, Elena was shoulder deep in hot water covered with a vanilla-scented foam. Her eyes were shut and the warmth was soaking into her body. The softly disintegrating salts were easing away all pain. These weren't ordinary bath salts. They had no medicinal smell, but they'd been given to her by Stefan's landlady, Mrs. Flowers, who was a genteel elderly white witch. Mrs. Flowers's herbal recipes were her specialty, and right now Elena would swear that she could feel all the tension of the last few days being actively sucked out of her body and gently soothed away. Oh, this was just what she had needed. Elena had never appreciated a bath like this before. Now, there's just one thing, she told herself firmly, as she inhaled breath after delicious breath of vanilla steam. You asked Mrs. Flowers for bath salts that would relax you, but you cannot fall asleep here. You'll drown, and you already know what that feels like. Been there, done that, didn't even have to buy the shroud. But even now Elena's thoughts were dimmer and more fragmented, as the hot water continued to relax her muscles, and the vanilla scent swirled around her head. She was losing continuity, her mind drifting off into daydreams†¦. She was giving herself to the heat and the luxury of not having to do anything at all†¦. She was asleep. In her dream, she was moving briskly. It was only half-light, but she could tell somehow that she was skimming downward through deep gray mist. What worried her was that she seemed to be surrounded by arguing voices, and they were arguing about her. â€Å"A second chance? I've spoken to her about it.† â€Å"She won't remember anything.† â€Å"It doesn't matter whether she remembers. Everything will remain inside her, if unawakened.† â€Å"It will germinate inside her†¦until the time is right.† Elena had no idea what any of it meant. And then this mist was thinning, and clouds were making way for her, and she was drifting down, more and more slowly, until she was deposited gently on a ground covered with pine needles. The voices were gone. She was lying on a forest floor, but she wasn't naked. She was wearing her prettiest nightgown, the one with real Valenciennes lace. She was listening to the tiny night sounds all around her when suddenly her aura reacted in a way that it never had before. It told her someone was coming. Someone who brought a sense of safety in warm earthen hues, in soft rose colors and deep, blue violets that enfolded her even before the person arrived. These were†¦someone's†¦feelings about herself. And behind the love and soothing concern she experienced, there were deep forest greens, shafts of warm gold, and a mysterious tinge of translucency, like a waterfall that sparkled as it fell and foamed like diamonds around her. Elena, a voice whispered. Elena. This was so familiar†¦. Elena. Elena. She knew this†¦. Elena, my angel. It meant love. Even as Elena was sitting up and turning in her dream, she was holding out her arms. This person belonged with her. He was her magic, her solace, her best-beloved. It didn't matter how he'd gotten there, or what had happened before. He was her soul's eternal mate. And then†¦ Strong arms holding her tenderly†¦ A warm body close to hers†¦ Sweet kisses†¦ Many, many times†¦ This familiar feeling as she melted into his embrace†¦ He was so gentle, but almost fierce in his love for her. He had vowed not to kill, but he would kill to save her. She was his most precious thing in all the world†¦. Any sacrifice would be worth it if she were safe and free. His life meant nothing without her, so he would gladly give it, laughing and kissing his hand to her with his last breath. Elena breathed in the wonderful autumn-leaves scent of his sweater and was comforted. Like a baby, she allowed herself to be soothed by simple familiar odors, by the feeling of her cheek against his shoulder and the wonder of the two of them breathing together in synchronicity. When she tried to put a name to this miracle, it was at the front of her mind. Stefan†¦ Elena didn't even need to look up at his face to know that Stefan's leaf-green eyes would be dancing like the waters of a small pond ruffled by wind and sparkling with a thousand different points of light. She buried her head in his neck, afraid somehow to let go of him, although she couldn't remember why. I don't know how I got here, she told him nonverbally. In fact, she didn't remember anything before this, before awakening to his call, only jumbled images. It doesn't matter. I'm with you. Fear seized her. This isn't†¦just a dream, is it? No dream is just a dream. And I'm with you always. But how did we get here? Shhh. You're tired. I'll hold you up. On my life, I swear it. Just rest. Let me hold you just once. Just once? But†¦ But now Elena felt worried and dazed, and she had to let her head fall backward, had to see Stefan's face. She tilted her chin back and found herself meeting laughing eyes of an infinite darkness in a chiseled, pale, and proudly handsome face. She almost cried out in horror. Hush. Hush, angel. Damon! The dark eyes that met hers were full of love and joy. Who else? How dare you – how did you get here? Elena was more and more confused. I don't belong anywhere, Damon pointed out, suddenly sounding sad. You know I'll always be with you. I do not; I do not – give Stefan back to me! But it was too late. Elena was aware of the sound of water trickling and of tepid liquid sloshing around her. She woke up just in time to keep her head from going underwater in the bathtub. A dream†¦ She felt much more flexible and easy in her body, but she couldn't help feeling saddened by the dream. It hadn't been an out of body experience, either – it had been a simple, crazy, mixed-up, dream of her own. I don't belong anywhere. I'll always be with you. Now what was gibberish like that supposed to mean? But something inside Elena trembled, even as she remembered it. She hastily changed – not into a Valenciennes lace nightgown, but into a gray and black sweat suit. When she emerged, she was feeling overtired and prickly and ready to start a fight if Damon gave any sign of having picked up on her sleeping thoughts. But Damon didn't. Elena saw a bed, managed to focus on it, stumbled toward it and collapsed, flopping down on pillows that sank unsatisfactorily beneath her head. Elena liked her pillows firm. For a few moments she lay, savoring her after-bath sensations, as her skin gradually cooled – and her head cooled as well. As far as she could tell, Damon was standing in exactly the same position as he had taken up when they'd entered the room. And he was still as silent as he had been since the morning. Finally, to get it over with, she spoke to him. And being Elena, she went straight to the heart of the problem. â€Å"What's wrong, Damon?† â€Å"Nothing.† Damon stared out the window, pretending to be engrossed in something beyond the glass. â€Å"What nothing?† Damon shook his head. But somehow, his turned back eloquently conveyed his opinion of this motel room. Elena examined the room with the too-bright vision of someone who has forced their body beyond its limits. She contemplated beige walls, beige carpet, a beige armchair, a beige desk, and of course, a beige bedspread. Even Damon couldn't reject a room on the grounds that it doesn't match his basic black, she thought, and then: oh, I'm tired. And bewildered. And scared. And†¦incredibly stupid. There's only one bed in here. I'm lying on it. â€Å"Damon†¦Ã¢â‚¬  With an effort, she sat up. â€Å"What do you want? There's a chair. I can sleep on the chair.† He half turned, and she saw in the movement that he wasn't annoyed or playing games. He was furious. It was all there in the faster-than-the-human-eye-could-follow assassin's spin and the complete muscular control that stilled it almost before it had begun. Damon with his sudden movements and his frightening stillness. He was looking out the window again, body poised as always for†¦something. Right now it looked poised to jump through glass to get outside. â€Å"Vampires don't need sleep,† he said in a voice icier and more controlled than she'd heard since Matt had left them. That gave her the energy to get off the bed. â€Å"You know I know that's a lie.† â€Å"Take the bed, Elena. Go to sleep.† But his voice was the same. She would have expected a flat, weary command. Damon sounded more tense, more controlled than ever. More shaken than ever. Her eyelids sank. â€Å"Is this about Matt?† â€Å"No.† â€Å"Is it about Shinichi?† â€Å"No!† Aha. â€Å"It is, isn't it? You're afraid that Shinichi will get past all your defenses and possess you again. Aren't you?† â€Å"Go to bed, Elena,† Damon said tonelessly. He was still shutting her out as completely as if she weren't there. Elena got mad. â€Å"What does it take to show you that I trust you? I'm traveling all alone with you, without any idea where we're really going. I'm trusting you with Stefan's life.† Elena was behind Damon now, on the beige carpet which smelled like†¦nothing, like boiled water. Not even like dust. Her words were the dust. There was something about them that sounded hollow, wrong. They were the truth – but they weren't getting through to Damon†¦. Elena sighed. Touching Damon unexpectedly was always a tricky business, with all the risks of setting off murderous instinct by accident, even when he wasn't possessed. She reached out, now, very carefully, to put her fingertips on the elbow of his leather jacket. She spoke as precisely and unemotionally as she could. â€Å"You also know that I have other senses now than the usual five. How many times do I have to say it, Damon? I know it wasn't you torturing me and Matt last week.† Despite herself, Elena heard a certain pleading in her own voice. â€Å"I know that you've protected me on this trip when I was in danger, even killing for me. That means – a lot to me. You may say you don't believe in the human sentiment of forgiveness, but I don't think you've forgotten it. And when you know that there is nothing to forgive in the first place – â€Å" â€Å"This has absolutely nothing to do with last week!† The change in his voice – the force in it – hit Elena like a whiplash. It hurt†¦and it frightened her. Damon was serious. He was also under some dreadful strain, not completely unlike that of fighting off Shinichi's possession, but different. â€Å"Damon†¦Ã¢â‚¬  â€Å"Leave me alone!† Now, where have I heard something like that before? Befuddled, her heart pounding, Elena groped through memories. Oh, yes. Stefan. Stefan when they had first been in his room together, when he was afraid to love her. When he was sure he would cause her to be damned if he showed he cared. Could Damon be that much like the brother he always mocked? â€Å"At least turn around and talk with me face-to-face.† â€Å"Elena.† It was a whisper, but it sounded as if Damon couldn't summon up his usual silky menace. â€Å"Go to bed. Go to hell. Go anywhere, but stay away from me.† â€Å"You're so good at that, aren't you?† Elena's own voice was cold now. Recklessly, angrily, she moved in even closer. â€Å"At pushing people away. But I know that you haven't fed this evening. There's nothing else you want from me, and you can't do the starving-martyr bit half as well as Stefan – â€Å" Elena had spoken knowing that her words were guaranteed to incite a response of some kind, but Damon's usual response to this sort of thing was to lounge against something and pretend not to have heard. What happened instead was completely outside the range of her experience. Damon whirled, caught her precisely, held her locked in an unbreakable grip. Then, with a swoop of his head like a falcon on a mouse, he kissed her. He was more than strong enough to hold her still without hurting her. The kiss was hard and long and for quite a while Elena resisted out of sheer instinct. Damon's body was cool against hers, which was still warm and damp from the bath. The way he was holding her – if she put enough pressure on those particular points, it would hurt her possibly seriously. And then – she knew – he would release her. But did she really know what she knew? Was she prepared to break a bone to test it? He was stroking her hair, which was so unfair, curling the ends and crushing them in his fingers†¦just hours after he'd taught her to feel things to the tips of her hair. He knew her weak spots. Not just every woman's weak spots. He knew hers; he knew how to make her want to cry out in pleasure and how to soothe her. There was nothing to do but test her theory and maybe break a bone. She would not submit when she had not invited him. She would not! But then she remembered her curiosity about the little boy and the great stone boulder, and she deliberately opened her mind to Damon's. He fell into the trap of his own making. As soon as their minds connected there were something like fireworks. Explosions. Rockets. Stars going nova. Elena set her mind to ignoring her body and began looking for the boulder. It was deep, deep inside the most locked-off part of his brain. Deep in the eternal darkness that slept there. But Elena seemed to have brought a searchlight with her. Wherever she turned, dark festoons of cobwebs fell and heavy-looking stone arches crumbled and fell to the ground. â€Å"Don't worry,† Elena found herself saying. â€Å"The light won't do that to you! You don't have to live down here. I'll show you the beauty of the light.† What am I saying? Elena wondered even as the words left her lips. How can I promise him – and maybe he likes living here in the dark! But in the next second she had come much closer to the little boy, close enough to see his pale, wondering face. â€Å"You came again,† he said, as if it were a miracle. â€Å"You said you would come, and you did!† That brought down all Elena's barriers at once. She knelt, and pulling the chains to their utmost length, took him on her lap. â€Å"Are you glad that I came back?† she asked gently. She was already stroking his hair smooth. â€Å"Oh, yes!† It was a cry, and it frightened Elena almost as much as it pleased her. â€Å"You're the nicest person I've ever – the most beautiful thing I ever – â€Å" â€Å"Hush,† Elena told him, â€Å"hush. There's got to be some way to warm you up.† â€Å"It's the iron,† the child said humbly. â€Å"Iron keeps me weak and cold. But it has to be iron; otherwise he wouldn't be able to control me.† â€Å"I see,† Elena said grimly. She was beginning to get a grasp on what kind of relationship Damon had with this little boy. For a moment, on a hunch, she took two lengths of iron in her hands and tried to tear them apart. Elena had super-light here; why not superpowers? But all that happened was that she twisted and turned the length for nothing, and finally cut the web of her finger against an iron burr. â€Å"Oh!† The boy's huge dark eyes fixed on the dark bead of blood. He stared as if he were fascinated – and afraid. â€Å"Do you want it?† Elena held out the hand to him uncertainly. What a poor scrap of a creature to be coveting other people's blood, she thought. He nodded timidly as if he were sure she'd be angry. But Elena just smiled and he reverently held her finger and took the whole globe of blood at once, closing his lips like a kiss. As he lifted his head, he seemed to have a tinge more color in his pale face. â€Å"You told me Damon keeps you here,† she said, holding him again and feeling heat being sucked from her into his cold body. â€Å"Can you tell me why?† The child was still licking his lips, but he turned his face toward her immediately and said, â€Å"I'm the Warden of Secrets. But† – sadly – â€Å"the Secrets have gotten so big that even I don't know what they are.† Elena followed the motion of his head from his own small limbs to the iron chain to the huge, metallic ball. She felt a sinking inside herself and a deep pity for such a small warden. And she wondered what on earth could be inside that great stone sphere that Damon was guarding so intently. But she didn't get the chance to ask.

The Two Types Of Symptoms Of Parkinson s Disease

The Two Types of Symptoms of Parkinson’s Disease Parkinson’s disease (PD), a degenerative nervous system disorder, is more common every day, yet it is still a mystery on what causes it. More than a million Americans have been diagnosed with PD and every year there are 60,000 new cases. Affecting older people, it is the second most common disorder and the condition is expected to increase as the aging population increases. PD essentially is the loss of dopamine-producing neurons. The increase in research has led to a wide range of possibilities to the causes involving both genetic and environmental factors. There are two different types of symptoms: motor and non-motor. The diagnosis of Parkinson’s disease can be challenging as the symptoms that are exhibited can also be symptoms of another neurodegenerative disorder (Gazewood 2013). There are no biological markers (tests or screenings) available for PD but researchers are working to develop an accurate one (PDF 2016). The cause of Parkinson’s disease is unknown but it is thought to be linked to combined effects of genetic factors and environmental factors. There is a greater risk of having Parkinson’s disease if someone in the family has been diagnosed with it. The genes linked to PD are SNCA, LRRK2, PARK2, and PINK1 (Lill et al. 2012). PD is also more common in non-Hispanic whites and in males (Van Den Eeden 2003). The environmental factors are pesticide exposure, occupational exposure, cigarette smoking or dietary factorsShow MoreRelatedIs Parkinson Disease A Disease?1290 Words   |  6 Pages Parkinson Disease Danielle West University Of Arkansas Fort Smith Medical Terminology Fall of 2015 Introduction Parkinson is a disease that is a glitch in the neurons in the brain, which frequently affects the substantia nigra. Part of the dying neurons produces a chemical called dopamine. As this progresses, the dopamine in the brain decreases. Dopamine is a chemical in the brain which helps the body regulate coordination and movement in the body. Once Parkinson Disease (PD)Read MoreOn Nervous Disorders : Parkinson s Disease1193 Words   |  5 PagesOn Nervous Disorders: Parkinson’s disease Parkinson’s disease is a progressive disorder of the nervous system characterized by tremor, slowed movement, and muscle rigidity; typically only seen in those over the age of forty. It is named after James Parkinson, an English surgeon, whom first described the symptoms of â€Å"the shaking palsy,† in a report published in 1817 (Grimes, 2004). The brain is the control center of the body. The brain orchestrates movement, sensations, feelings, personality, andRead MoreThe Common Types Of Dementia1013 Words   |  5 PagesIt’s a progressive disease which means it gets worse over time. If diagnosed early on, the quality of life for people with dementia as well as their family members can be significantly improved. There are many different types of dementias although some are far more reciprocal than others. One of the most common types of dementia is Alzheimer’s disease. Other few types of dementias are â€Å"Vascular dementia, Mixed dementia, Parkinson s disease and Frontotemporal dementia (Krishnan, D. S)†. All of the variousRead MoreParkinson Disease ( Pd )1350 Words   |  6 Pages Parkinson disease (PD) is one of the most common neurologic disorders. and it affects approximately 1% of individuals older than 60 years old. Parkinson’s disease is a condition that progresses slowly by treatment. In addition, loss of pigmented dopaminergic neurons of the substantianigra pars compacta and the presence of Lewy bodies and Lewyneurites are the two major neuropathologic findings in Parkinson disease (Hauser, 2016). The cause of Parkinson disease, defined by Robert Hauser, who isRead MoreParkinson s Disease : Disease1737 Words   |  7 Pages Parkinson’s disease Parkinson’s Disease INTRODUCTION Wong, Gilmour and Ramage-Morin (2014) states that Parkinson’s disease comes second on the list of most common degenerative disorder of the nervous system. Dopamine, a substance synthesized in the body, is responsible for the normal movements of the body (Wong, Gilmour and Ramage-Morin, 2014). In Parkinson’s disease, the cells responsible for synthesizing Dopamine are damaged and incapacitated to form it (Wong, GilmourRead MoreThe Purpose Of My Research Conducted For This Paper Was1677 Words   |  7 Pagesrelationship between Parkinson s disorder and its connection to the anatomy of the human body. Parkinson s is a progressive disorder of the nervous system that affects movement due to the loss of Dopamine. Dopamine which is a neurotransmitter located in the brain allows signals to be transported from one nerve cell to another. Its purpose is to regulate both movement and cognition. The loss of these chemical messengers can cause both stiffness of the body and tremors, which are two common effects ofRead More Parkinson’s Disease and Medical Treatment Options Essay1544 Words   |  7 PagesParkinson’s Disease and Medical Treatment Options For many 50 year olds, tasks such as writing or walking can be easily preformed without much attention. In fact, the term â€Å"task† seems to stress that there is a greater level of effort than is truly exerted in order for the average person to perform these actions. However, for a patient of Parkinson’s Disease who is diagnosed on average at the age of 50, these every day activities take a great deal of time, attention, and effort to be preformedRead MoreDementia With Lewy Bodies ( Dlb )1473 Words   |  6 PagesDementia with Lewy bodies (DLB) is a type of dementia that shares symptoms with both Alzheimer s disease and Parkinson s disease. It may account for around 10 per cent of all cases of dementia (Alzheimer’s Society, 2016). Lewy refers to the inflammation or neuro-inflammation of the brain (Surendranathan et al, 2015). Both Parkinson s disease and dementia with Lewy bodies are age-related diseases, although onset before age 65 years is not uncommon and both diseases are more common in men than in womenRead MoreThe Disease Of Parkinson s Disease1648 Words   |  7 Pages Abstract Parkinson’s disease has been cataloged as one of the most serious and slowly progressive neurodegenerative disease that affects a wide array of motor and non-motor aspects that impact the function of a person. Afflicting over four million Americans and the second most common neurological disorder after Alzheimer’s disease, Parkinson’s continues to take its toll on the neurological health of many(Constantinescu et al, 2007 ). James Parkinson, a British physician first coinedRead MoreParkinson s Disease : Disease3496 Words   |  14 Pages Parkinson s disease Twanda H. Lewis North Carolina Wesleyan Dr. Quinan Parkinson s Disease Twanda H. Lewis North Carolina Wesleyan Dr. Quinan Outline Abstract†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦5 Introduction†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 Symptoms†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 Tremor†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.†¦ 6 Slow Movement†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Rigid Muscles†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Disfigured Posture†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Loss

The Sociological Imagination By C. Wright Mills - 857 Words

The sociological imagination is simply the act of having the capacity to think ourselves away from the commonplace schedules of our day by day lives keeping in mind the end goal to take a gander at them with a new perspective. C. Wright Mills, who made the idea and composed a book about it, characterized the sociological creative ability as the clear attention to the connection amongst encounter and the more extensive society. The sociological imagination is the capacity to see things socially and how they interface and impact each other. To have a sociological imagination, a man must have the capacity to pull far from the circumstance and think from an option perspective. This capacity is key to ones improvement of a sociological†¦show more content†¦One route in which one can consider this, is to perceive how what we regularly encounter as individual inconveniences, like not having enough cash to pay our bills, are really open issues - the after effect of social issues tha t course through society and influence many, as fundamental financial disparity and basic neediness. Whats more, Mills prescribed dodging strict adherence to any one technique or hypothesis, on the grounds that honing human science in such a way can and regularly does delivered one-sided results and suggestions. He additionally asked social researchers to work inside the field of sociology in general as opposed to practicing vigorously in human science, political science, financial aspects, brain research, and so forth. While C Wright Mills thoughts were progressive and disquieting to numerous inside human science at the time, today they frame the bedrock of sociological practice. We can apply the idea of the sociological creative ability to any conduct. Take the straightforward demonstration of drinking some coffee, for instance. We could contend that coffee isnt only a drink, but instead it has emblematic incentive as a feature of everyday social customs. Regularly the custom of drinking coffee is substantially more vital than the drinking then coffee itself. For instance, two individuals who meet to haveShow MoreRelatedSociological Imagination By C. Wright Mills969 Words   |  4 Pages C. Wright Mills defined sociological imagination as the awareness of the relationship between personal experience and the wider society. Understanding and being able to exercise the sociological imagination helps us understand the relationship between the individual and society. Mills focuses on the distinction between personal troubles and public issues. Having sociological imagination is critical for individual people and societies at large to understand. It is import ant that people areRead MoreThe Sociological Imagination : C. Wright Mills907 Words   |  4 Pagesindividual s life a person will experience what C. Wright Mills refers to as the trap. The trap alludes to a person that can only see and understand their own small scope of life. Their frame of reference is limited to their day to day life and personal experiences that are directly related to them, they cannot see the bigger picture. They do not yet know that the sociological imagination can set them free from this trap and as C. Wright Mills said, In many ways it is a terrible lesson; in manyRead MoreThe Sociological Imagination By C. Wright Mills1315 Words   |  6 Pagesâ€Å"The sociological imagination enables us to grasp history and biography and the relations between the two within society. This is its task and its promise.† C. Wright Mills writes about the sociological imagination in an attempt to have society become aware of the relationship between one’s pe rsonal experience in comparison to the wider society. By employing the sociological imagination into the real world, individuals are forced to perceive, from a neutral position, social structures that, inRead MoreThe Sociological Imagination By C. Wright Mills986 Words   |  4 PagesMills Chapter Summary â€Å"Yet Men do not usually define the troubles they endure in terms of historical change and institution contradiction.† Stated from chapter one of â€Å"The Classic Readings in Sociology† which was based on â€Å"The Sociology Imagination† by C. Wright Mills. As our Sociology 131 class study the works of C. Wright Mills, we learn and examine his views. We learn how he view other things such as marriage, war, and the limitations of men. His view of war is that both sides playRead MoreSociological Imagination By C. Wright Mills942 Words   |  4 PagesSociological imagination according to C. Wright Mills (1959) â€Å"enables its possessor to understand the larger historical scene in terms of its meaning for the inner life and the external career of a variety of individuals† (p.5) Mills in this book of The Sociological Imagination explains how society shapes the people. Mills wants people to be able to use sociological imagination to see things in a sociology point of view, so they can know the difference between personal troubles versus personal issuesRead MoreSociological Imagination, By C. Wright Mills Essay1611 Words   |  7 PagesI SOCIOLOGICAL IMAGINATION CONCEPTUALIZATION As conceived by C. Wright Mills, sociological imagination is the mental ability to establish intelligible relations among social structure and personal biography that is observing and seeing the impact of society over our private lives. Sociological imagination helps an individual to understand on a much larger scale the meaning and effect of society on of one’s daily life experience. People blame themselves for their own personal problems and they themselvesRead MoreThe Sociological Imagination, By C. Wright Mills799 Words   |  4 Pages The sociological imagination, a concept used by C. Wright Mills, is essentially the ability to perceive a situation or act in a much larger social context as well as examining the situation or act from many perspectives. In particular, it plays a paramount role in Donna Gaines Teenage Wasteland. It is a tragic story of 4 teens who together, committed suicide. The teens were deemed as â€Å"dropouts, druggies† [Teenage Wasteland 8.2 ] by newspapers and were still treated with disdain even after theirRead MoreThe Sociological Imagination : C. Wright Mills1822 Words   |  8 PagesC. Wright Mills defines the sociological imagination as, â€Å"what they need, and what they feel they need, is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves†. Mills also says that the sociological imagination enables us to grasp history and biography and the relations between the two within society. When I read Chapter One: The Promise from C. WrightRead MoreThe Sociological Imagination, By C. Wright Mills1692 Words   |  7 Pagesentire life, can be determined by examining his or her intellect, high school performance, and talents. However, C. Wright Mills proposes a new approach to this idea in his work, â€Å"The Promise.† Mills presents an idea known as the sociological imagination, which examines society on a larger scale to better grasp an individual’s life circumstances (Mills 2). The sociological imagination examines the role of social forces on the lives of individuals (Butler-Sweet, September 5, 2017). For example,Read MoreSociological Imagination, By C. Wright Mills1762 Words   |  8 Pages 10/11/2017 ID 100602667 Soc. 1 FY40 Sociological Imagination The Sociological Imagination, by C. Wright Mills, was a statement that questioned the developing field of sociology, challenging sociologists and the public to take seriously the rise of elites and the decline of American democracy, American community, and American equality. Mills argues that the sociological imagination is a quality of mind necessary to the understanding of the human condition