COPD Case Study Assignment

COPD Case Study Assignment 1) CASE SUMMARY Mr TLT is a 58 year old taxi driver who was admitted to Hospital Batu Pahat due to newly diagnosed chronic obstructive pulmonary disease. He has had hypertension for the past one year and is taking T Amlodipine 5mg od. He is also a chronic smoker for the past 40 years who smokes about 20 sticks of cigarettes a day. Mr TLT presented with shortness of breath which progressively increased in severity for the past 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory tract infection. Mr TLT has been having intermittent chronic cough associtaed with mucoid sputum for the past 3 years. He has also been having persistent breathlessness for the past 1 year especially on exertion. He has not sought treatment prior to this admission. On physical examination, Mr TLT was tacypnoiec with a respiratory rate of 28 breaths per minute. There was no cyanosis. Repiratory system examination showed use of accesory muscles as well as increased anterior posterior diameter of the chest and reduced cricosternal distance. On auscultation, vesicular breathing was heard with generalised rhonchi and coarse early inspiratory crepitations at the lower zone of both lungs. The cardiovascular system examination was normal. There were no other abnormalities on physical examination. Investigations done include chest plain radiograph which showed a hyperinflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No P pulmonale indicative of right atiral hypertrophy seen. A working diagnosis of acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection was made. Mr TLT was given nebulization of ipratropium bromide, salbutamol and normal saline for 2 times. His symptoms improved after being given the nebulization. He was discharged after three days when the dyspnoea had resolved. He was given metered dose inhaler of Ipratropium Bromide 40microgrammes tds and MDI salbutamol 200microgrammes PRN. He was given an appointment to assess his symptoms at the outpatient department in one month time. STUDENT NAME: Tan Hai Liang ID NO : M0409146 NAME OF SUPERVISOR : Prof Khin ROTATION: Internal Medicine PATIENTS DETAILS I/C NUMBER : 510912-01-6343 AGE : 58 SEX : Male DATE OF ADMISSION : 2 June 2009 R/N NUMBER : 1143451 2) CLINICAL HISTORY Chief complaint: Mr TLT is a 58 year old taxi driver who presented with shortness of breath for the past four days. History of present illness: Mr TLT is a chronic smoker for the past 40 years who has been smoking about twenty sticks of cigarettes a day. He had been diagnosed with hypertension for the past one year and is currently on T Amlodipine 5 mg od. Mr TLT has been having intermittent chronic cough for the past 3 years. The cough is productive at times. The sputum produced is mucoid in nature and about one tablespoonful in amount. There is no blood in the sputum. It is also not foul-smelling. Mr TLT then proceeded to have shortness of breath for the past one year. The dyspnoea is persistently present and described as requiring increased effort to breathe. It is worse on exertion and Mr TLT experinces reduced effort tolerance. He is now able to climb one and a half flights of stairs before becoming breathless. He has not consulted any doctors for these symptoms prior to admission. Mr TLT then developed symptoms of upper respiratory tract infection such as rhinorrhea and sore throat one week prior to admission. He had fever of 38 degress celcius at that time which resolved with paracetamol. He also had a productive cough with mucoid sputum at this time. Mr TLT then developed increasing shortness of breath 4 days prior to admission. The shortness of breath worsened over the 4 days and was associated with noisy breathing. He was breathless even at rest but was still able to speak in sentences. There was also an increase in cough as well as production of sputum. The sputum was mucoid and non purulent. He also did not notice any blueness around his lips or at his fingers. Systemic review: There was no loss of appetite or loss of weight. He had mild ankle oedema but no other signs of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea. Past medical history Mr TLT has not had any hospital admissions prior to this. He was diagnosed with hypertension last year as an incidental finding during a visit to the kilinik kesihatan for an upper respiratory tract infection. He is currently taking tablet Amlodipine 5 mg once daily. Family history Mr TLT is the eldest of 5 siblings. There is a strong family history of hypertension in that his mother as well as two other siblings are also hypertensive. There is no family history of asthma, diabetes or ischaemic heart disease. Social history Mr TLT used to work as a taxi driver but has stopped working full time 2 years ago. He still occasionally drives his taxi but spends more time at home with his family. He is a chronic smoker for the past 40 years and smokes about 20 sticks of cigarrettes a day. He drinks alcohol with his friends on weekends. He drinks one to two bottles of beer each time. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine ____________________________________________________________________________ 3) FINDINGS ON CLINICAL EXAMINATION On general examination, Mr TLT was well nourished and alert but was tachypnoiec. He was able to speak in sentences but there was use of his accessory muscles. There was no clubbing or cyanosis seen. There was also no peripheral oedema, pallor or jaundice. Vital signs: Pulse rate: 72 beats per minute, regular with good volume. No bounding pulse. Respiratory rate: 28 breaths per minute Blood pressure: 129/73 Temperature: 37 degrees Celsius SpO2: 95% under nasal prong oxygen 3 litres per minute Examination of the respiratory system: On inspection of the hands, there was no peripheral cyanosis or flapping tremors seen. There was also no clubbing, muscle wasting or palmar erythema seen. There was presence of nicotine stains. The jugular venous pressure is mildly elevated at 3.5 cm above the sternal angle. On palpation of the trachea, the trachea is central but the cricosternal distance is 2 fingers which is reduced. The apex beat could not be palpated. On inspection of the chest, there is an increased anterior posterior diameter giving rise to a barrel shaped chest. The chest moves equally with respiration and there is use of accessory mucles with intercostal, subcostal and suprasternal retraction. There are no chest wall deformities. On palpation, chest expansion is reduced on both sides. Tactile fremitus is equal on both sides. On percussion, there is hyperresonance over both lungs with loss of liver and cardiac dullness. On auscultation vesicular breathing is heard. There is generalised expiratory rhonchi. There is also fine early inspiratory crepitations heard at the lower zones of both lungs. Examination of the cardiovascular system: The apex beat could not be palpated. There were no parasternal heaves or thrills palpable. On auscultation, normal first and second heart sounds were heard. There was mild bilateral pitting oedema. Examination of the abdomen: On inspection, the abdomen is flat and moves with respiration. There was no guarding or tenderness. The liver and spleen were not palpable. There was no organomegaly. Examination of the neurological system was normal. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional diagnosis: Acute exacerbation of newly diagnosed chronic obstructive airway disease due to upper respiratory tract infection. Evidence for: Patients with chronic obstructive airway disease (COPD) usually present with a persistent dyspnoea and reduced effort tolerance which was present in the history given by Mr TLT. He is also at increased risk of developing COPD due to exposure to associated risk factors such as tobacco smoke. He has been a chronic smoker for the past 40 years. There is also the presence of chronic cough occasionally associated with mucoid sputum which further suggests COPD. Physical findings of a hyperinflated chest and vesicular breathing with generalised expiratory rhonchi also point to an obstructive airway disease. During this admission Mr TLT had increasing severity of shortness of breath even at rest. This was associated with a wheeze that was described as noisy breathing. Sudden worsening of symptoms suggest an episode of acute exacerbation. The history of upper respiratory tract infection symptoms suggest that it was the trigger for this episode of exacerbation. Differential diagnosis: 1) Congestive cardiac failure. Mr TLT may have developed congestive cardiac failure as a primary event or as a complication of chronic lung disease. There is history of reduced effort tolerance. Patients with congestive cardiac failure may also present with a wheeze and sudden increase in dyspnoea. Physical examination of fine crepitations at both bases of the lungs may also indicate congestive cardiac failure. There is also evidence of mildly raised JVP as well as mild pittint ankle oedema. Evidence against: There is no history of any cause of heart failure such as ischaemic heart disease or cardiac valve defect. Mr TLTs previous records during follow-up show well controlled blood pressure. Additional investigations need to be carried out in order to rule out this condition. A chest plain radiograph may be done in order to look for evidence of heart failure such as cardiomegaly. An ECG may be done to look for right atrial hypertrophy. An echocardiogram should also be performed in order to assess the function of the ventricles. 2) Bronchiectasis Patients with bronchiectasis have a history of chronic cough as well as production of copious amounts of sputum. They may also have persistent shortness of breath, reduced effort tolerance and wheeze. Evidence against: The sputum produced by Mr TLT is mucoid in nature and not purulent which is typical in bronchiectasis. It is also not copious and foul smelling in nature. On physical examination, coarse crepitations would be heard in bronchiectasis as opposed to the fine crepitations heard in Mr TLT. There is also no evidence of clubbing. Chest plain radiograph should be done in order to look for thickened bronchial walls or cystic shadows. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Shortness of breath and reduced effort tolerance Mr TLTs chief complaint is shortness of breath. This may be attributed to the increase in number of goblet cells and later on fibrosis of the bronchial walls causing airway obstruction seen in chronic obstructive airway disease. The shortness of breath may be partially relieved with the use of nebulization of ipratropium bromide, salbutamol and normal saline or with the use of metered dose inhalers. Chest physiotherapy may also be useful. Mr TLT also has had reduced effort tolerance and persistent dyspnoea for the past a year. As such he may require the use of ipratropium bromide in a metered dose inhaler upon discharge in order to feel less breathless due to the bronchodilator effect of the ipratropium bromide. 2. Upper respiratory tract infection Mr TLT may require antibiotics as he still has symptoms of upper respiratory tract infection such as sore throat. Furthermore patients who present with an acute exacerbation are at greater risk of having a bacterial infection. This is because of the depressed immune state that the patient is in as a result of the acute illness as well as due to any steroids that would be given as part of the management plan. The appropriateness of usage of antibiotics in chronic obstructive airway disease will be further discussed below. 3. Adequate inhaler technique Mr TLT would need to be taught about the correct technique to be used when using metered dose inhalers. He would probably require daily use of ipratropium bromide metered dose inhalers to reduce his breathlessness. In the event that he is unable to learn proper technique, he may be encouraged to buy an aerochamber. 4. Smoking cessation Mr TLT should be counseled on smoking cessation as it has been proven that smoking cessation would alter the course of progression in COPD and is associated with lower all-cause mortality. He should be counseled on the various options of smoking cessation which will be discussed further below. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1) Full Blood Count Justification: In order to view the total white count as well as the differential count to see if there is an infection which has caused this episode of exacerbation. There may also be secondary polycythemia if the patient has chronic pulmonary hypertension. Results: White cell count : 7.91 X 109/L Red blood cell : 4.48 X 1012/L Haemoglobin : 133.00 g/dl Haematocrit : 42.00 ratio Mean cell volume : 93.80 fL Mean cell haemoglobin : 29.70 pg Mean cell haemoglobin conc. : 317.00 g/l Platelets : 141.00 X 109/L Differential count Neutrophils : 60.10% 4.76 X 109/L Lymphocytes : 25.30% 2.00 X 109/L Monocytes : 13.80% 1.09 X 109/L Eosinophils : 0.50% 0.04 X 109/L Basophils : 0.30% 0.02 X 109/L Interpretation: This is a normal full blood count result with normal total white count as well as normal haemoglobin levels. 2) Plain chest radiograph Justification: Done in order to look for evidence of chronic obstructive airway disease such as hyperinflated chest or evidence of congestive cardiac failure such as cardiomegaly and prominent upper lobe vessels. Results: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No other abnormalities seen. Interpretation: Hyperinflation of the lung fields is consistent with the provisional diagnosis of chronic obstructive airway disease. 3) Sputum FEME, culture and sensitivity (not done) Justification: In order to look for any bacteria which may have been the cause of the exacerbation . If there any organism cultured, proper antibiotics can be given based on the sensitivity test. 4) Arterial blood gas (not done) Justification: May be necessary in severe cases of breathlessness to look for respiratory failure and associated changes in blood pH. 5) Blood urea serum electrolytes and creatinine Justification: To look for renal impairment which may be present due to Mr TLT having hypertension. Renal impairment may also affect the dosage and type of antibiotics used. Results: Urea : 3.7mmol/L Sodium : 135 mmol/L Potassium : 3.7 mmol/L Creatinine : 65 umol/L Interpretation: Normal result. There is no renal impairment 6) Electrocardiogram Justification: To look for evidence of right ventricular hypertrophy or right atrial hypertrophy which may be seen in chronic lung disease. Results: ECG with sinus rhythm. There is no P pulmonale seen. There is low voltage seen. No ischaemic changes seen. No left ventricular hypertrophy. Interpretation: Normal ECG with low voltage is seen in a hyperinflated chest such as in patients with COPD STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working diagnosis: Acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection My proposed plan of management is as follows: Acute management 1. Provide supplemental oxygen via nasal prong 3L/min and maintain SpO2 above 90%. Arterial blood gas should be done in order to ensure adequate oxygenation without carbon dioxide retention of acidosis. 2. Close monitoring of vital signs and SpO2 hourly until the patients breathlessness improves. Nursing staff to inform if patient deteriorates such as increased respiratory rate or drop in oxygen saturation below 92%. 3. Give nebulization of Ipratropium Bromide:Salbutamol:Normal Saline in ratio of 2:2:1 every four hours until breathlessness decreases. 4. Oral prednisolone 40mg once daily for 10 days 5. Postural drainage and chest physiotherapy may be performed. 6. Oral antibiotics such as T. Cefuroxime may be given. This was not given in this patient with further discussion below. Long term management 1. MDI ipratropium bromide 40 microgrammes tds 2. MDI salbutamol 200 microgrammes PRN 3. Counseling on proper inhaler technique. 4. Couseling on smoking cessation. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES) Mr TLT was warded for a total of 3 days. His breathlessness improved after nebulization with ipratropium bromide, salbutamol and normal saline for one day. He no longer required nebulization after one day. Mr TLT was also able to ambulate without feeling breathless. He was able to eat and to sleep well without being bothered by the dyspnoea. His vital signs were also normal and his respiratory rate improved to about 20 breaths per minute. There was still some ronchi heard on auscultation but it was much reduced. He was afebrile during his stay. Mr TLT was discharged after 3 days of admission and educated on chronic obstructive airway disease. He was also counseled on the importance of smoking cessation. He was given an appointment with the medical outpatient department in one month time in order to review his symptoms after being given MDI ipratropium bromide. He was told to return to the hospital if he had similar episodes. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge Plan 1. Medications: i. MDI Salbutamol 200 µg PRN ii. MDI Ipratropium Bromide 40 µg TDS iii. T. Amlodipine 5mg once daily iv. T. Prednisolone 20mg od for 7 days. 2. Counseling on COPD and use of metered dose inhaler Mr TLT should be taught about the correct technique in using a metered dose inhaler. The technique should then be assessed before discharge. In the event that Mr TLT is unable to coordinate well, he may be advised to purchase an aerochamber. 3. Counseling on smoking cessation The approach to counseling a patient on smoking cessation as well as various options will be further discussed below. 4. Education on the symptoms of an acute exacerbation and advise to return to the hospital if there is development of those symptoms. 5. For follow-up at the medical outpatient department for review of symptoms while on MDI ipratropium bromide. He should also be taught about pulmonary rehabilitation. A spirometry appointment may also be made. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 10) REFERRAL LETTER (MANDATORY) Dr Tan Hai Liang Medical Department, Hospital Batu Pahat Family physician, Klinik Kesihatan Batu Pahat, 83000 Batu Pahat, 10 June 2009 Dear esteemed colleague, Patients name: Teo Lai Thing Patients I/c number: 510912-01-6343 Problem: Chronic Obstructive Airway disease Thank you for seeing this 58 year old gentleman who is hypertensive for the past 1 year currently on T. Amlodipine 5mg once daily. He presented to Hospital Batu Pahat with shortness of breath for 4 days that was increasing in severity. A diagnosis of chronic obstructive airway disease was made. He was discharged uneventfully on the third day of admission with the following medication: MDI Salbutamol 200 µg PRN, MDI Ipratropium Bromide 40 µg TDS and T. Amlodipine 5mg once daily. Mr Teo has been a chronic smoker for the past 40 years and smokes up to 20 sticks of cigarettes a day. We have counselled him about the benefits of smoking cessation while in the ward. He is currently considering it and would like to learn more about the various options of smoking cessation. Kindly assess the patients keenness for smoking cessation as well as provide him with additional information on the options available to quit smoking. Thank you. Sincerely ____________ (Tan Hai Liang) Medical Department Hospital Batu Pahat STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 11) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1) Communication skills What are the benefits of smoking cessation in COPD patients and how should counseling be done? Counseling for smoking cessation should play a significant role in the holistic management of a patient with chronic obstructive airway disease. This is because studies have shown that smoking cessation changes the clinical course of COPD by preserving lung function. One study of patients reviewed at 14.5 years after stopping smoking showed that smoking cessation intervention showed 18% reduction in all-cause mortality compared with usual care without smoking cessation intervention. Patients who had stopped smoking had lower rates of death due of coronary heart disease , cerebrovascular disease, lung cancer, and other respiratory disease as compared with those assigned to usual care who continue to smoke. [1] Fig. 4. Effect of smoking cessation on mortality cause at 14.5 years in the Lung Health Study. (A) Comparison of smoking cessation intervention with usual care. (B) Comparison according to smoking status. I therefore looked up for counseling methods for smoking cessation. The American College of Chest Physicians recommend that physicians should be the first line in introducing smoking cessation. [2] There are 5 As that a doctor should perform for a patient who is a smoker: †¢ Ask about tobacco use at every visit †¢ Advise tobacco users to quit †¢ Assess the willingness to attempt quitting †¢ Assist the patient with methods for quitting †¢ Arrange for follow-up contact via phone or face to face If the patient is not yet willing to quit, there are 5 Rs which should be identified together by the patient and the doctor: †¢ Relevance of quitting for the patient †¢ Risks of illness related to continued tobacco use †¢ Rewerds/benefits of smoking cessation †¢ Roadblocks for quitting, internal and external †¢ Repetition of the motivation intervention at each encounter There are two means of intervention in smoking cessation namely pharmacological and behavioural. The pharmacological means include nicotine replacement therapy or buproprion. Behavioural interventions include counseling programs that teach problem-solving skills and support groups. [3] In conclusion, I learned that doctors have an important role in actively encouraging patients who smoke to stop as there are many proven benefits of smoking cessation. The steps discussed above on techniques in the counseling of patients would be helpful to me in the future. 2) Professionalism, ethics and personal development Should antibiotics be given for episodes of exacerbation of chronic obstructive airway disease? Mr TLT was not given antibiotics during this episode of exacerbation. Certain quarters support the use of prophylactic antibiotics in all exacerbations due to the knowledge that most exacerbations are caused by the common organisms of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), Pseudomonas aeruginosa (P. aeruginosa) and Moraxella catarrhalis (M. catarrhalis). Sputum culture may not be useful as even in the clinical stable state, some patients have sputum positive for bacteria. As such a broad spectrum antibiotic is usually used to cover different bacteria. However, is this use of antibiotics justified in that do patients benefit from it or is the overjudicious use of antibiotics merely promoting antibiotic resistant bacteria? Current Global initiative for chronic Lung Disease guidelines [4] recommend that antibiotics should be given in: i) patients with exacerbations of COPD and the three cardinal symptoms of increased dyspnoea, increased sputum volume and increased sputum purulence. ii) patients with exacerbation of COPD with two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms iii) patients with severe exacerbations of COPD that requires mechanical ventilation A meta-analysis by Ram et al [5] of 11 placebo controlled RCTs with 917 patients attempted to analyse the value of antibiotics in the management of acute COPD exacerbations. The results show that there is a decrease in short-term mortality, treatment failure and sputum purulence with antibiotic therapy compared to placebo. The authors concluded that antibiotics therapy is appropriate in exacerbations of COPD associated with increased cough and sputum purulence. They further found that antibiotics have the greatest effect for patients with severe exacerbations who are admitted to the hospital. They were unable to comment on exacerbations with non-purulent sputum, what antibiotics were the best to be used and also the duration of therapy due to the lack of RCTs done on these aspects. In conclusion, it was appropriate that Mr TLT was not given antibiotics as he did not have the cardinal signs as mentioned by the GOLD guidelines and further supported by the systemic review. 3) Self directed life long learning What are extrapulmonary manifestations of COPD and what are its therapeutic implications? Chronic obstructive lung disease has long been known as a localized pulmonary disorder. However new evidence have shown that COPD may be a systemic disease that involves pathology in several extra-pulmonary systems. An article by Remels et al [6] summarized the extrapulmonary manifestations as well as its implications on the holistic management of chronic obstructive airway disease. The article showed that there is skeletal muscle dysfunction as well as systemic inflammation in chronic obstructive airway disease. There is loss of muscle mass associated with impaired protein metabolism. The loss of muscle mass which is called sarcopenia may progress to cachexia. Studies have also shown that there is increased apoptosis of muscle cells at the cellular level. Independent of the loss of muscle mass is the reduced muscle endurance. This finding has been attributed to abnormalities in mitochondria or to hypoxia. These findings have significant implications on management of a COPD patient which will be discussed below. Systemic inflammation is also seen in patients with COPD. This is evidenced by elevated levels of the proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-a), interleukin-6, interleukin-8, and TNF-a receptors. The origin of the systemic inflammation is thought to be independent of the pulmonary manifestation of COPD. One postulation is the increase systemic inflammatory mediators such as neutrophils and lymphocytes in the circulation of patients with COPD. Another proposed mechanism is increased cytokine production due to chronic hypoxia. The therapeutic implications of these findings is that muscle atrophy should be prevented by resistance exercise as well as combined strength and endurance exercise. Current Malaysian guidelines on the management of COPD [7] recommend pulmonary resistance including lower and upper limb exercises as well as inspiratory muscle training. This concurs with a Cochrane metaanalysis by Lacasse et al [8] which strongly support respiratory at least four weeks of exercise training as part of the of management for patients with COPD. The authors found that there was clinically and statistically significant improvements in quality of life as measured by dyspnea, fatigue and emotional function. 4. Critical thinking and research What is the efficacy of systemic corticosteroids for acute exacerbations of chronic obstructive airway disese? The use of systemic oral or intravenous corticosteroids is recommended by GOLD guidelines in the management of acute exacerbations of chronic obstructive airway disease. However the patient, Mr TLT was not given any systemic corticosteroids. This could be because he merely had a mild exacerbation. I therefore looked up a Cochrane metaanalysis on the use of systemic corticosteroids for acute exacerbations of chronic obstructive airway disease [9]. The authors reviewed randomized controlled trials comparing parenteral or oral corticosteroids with placebo for the treatment of exacerbation of COPD. The primary outcomes measured were treatment failure (hospital readmission, return to emergency department), relapse and mortality. The authors reviewed 11 studies involving 1081 participants. The results show a statistically significant difference between placebo and use of corticosteoids. There was less treatment failure in patients given corticosteroids. Relapse within 30 days were also reduced. However there was no statistically significant reduction in mortality. As such the authors concluded that administration of oral or parenteral corticosteroids in the treatment of acute exacerbations of COPD reduces the likelihood of treatment failure. This is associated with early and continuing improvement during treatment with corticosteroids in lung function, breathlessness and blood gases and with a shorter hospital stay. This in turn has a positve impact on the economic cost of treating exacerbations, with fewer follow-up visits and hospital admissions. The authors also found that although there is an increased incidence of corticosteroid side effects such as fluid retention, hypertension and adrenal suppression, the effects are unlikely to persist after treatment ceases. EVIDENCE BASED MEDICINE WORKSHEET FOR REVIEW OF THERAPY STUDIES ASKING QUESTION Patient (P): Patients who present with stable COPD Intervention (I): Oral corticosteroids Comparison (C): Placebo Outcome (O): Effects on health status ACCESSING EVIDENCE THE SEARCH PATH How was the article identified: The Cochrane Library Search keywords : corticosteroids, stable COPD Citation: Walters JAE,Walters EH,Wood-Baker R.Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 3. 1. Is

Fairy Tale Love Essays -- essays papers

Fairy Tale Love Once upon a time there was a beautiful young woman. She had bleached blonde hair, sparkling ocean blue eyes, and a super model figure. After struggling with life’s challenges for a few years a strong, dark, handsome stock broker came along and rescued her. It was love at first sight. They got married, had one boy and one girl (in that order), and then lived happily ever after. At one point in time I believed this modern day dream was a realistic outlook on love. My opinion of this fairy tale story has been changed throughout the lessons of this course. I set my expectations as a child as to what love should be. Through movies, TV, magazines, and music these ideas were implanted in my mind. This course and personal experiences have opened my eyes to a more realistic approach to love. In the beginning, we are all naà ¯ve and innocent. Characters such as Charity from Summer portrays this idea. I related to her naivetà © and remembered how easily I became blinded by love. After becoming romantically involved with Harney, she was swept up by her emotions and lost all contact with reality. â€Å"He had caught her up and carried her away into a new world† (Summer 178). The first time I fell in love, I believed that the world revolved around him just as Charity did with Harney. I became oblivious to reality and the truth of the situation. My love as well as Charity’s, was so bent by the truth that we could only see what we wanted to. Charity was swept up in this fairy tale love that she believed would never end. When reality finally overtook her, she could not find the strength to overcome the black and white situation in front of her. â€Å"She had not the strength to shake off the spell that bound, she saw only the par... ...thought with one mind, and maintained an annoying privacy† (39). I thought romantic love should be like their bond, private and consumed in their own domain like Charity and Harney. This class has taught me to look beyond the set construct that modern day culture presses on us. I believe that love is the most abstract concept humans try to conceive. I do not think that any one view love is correct. As you age and mature, your impressions of love change. The main point I got out of the class was just the simple idea of looking past the emotions that are so unconstrained, to see the situation and true meaning for what it really is. In the future, I will no longer approach relationships and love as the fairy tale concept. Because in the end there is no happily ever after. Bibliography: Wharton, Edith. Summer. New York: Simon and Schuster 1917.

3 Basic Inventory Techniques or Cost Flow Assumptions: Fifo (Stands for First-in, First-Out), Lifo (Stands for Last-in, First-Out) and Wavg (Stands for Weighted †Average)

4. 3| As a management accounting compare and contrast the above methods and recommend suitable method to achieve the organizational objective| P2. 3,M3. 3,D1. 1| Assignment| One of the most important knowledge about accounting is 3 basic inventory techniques or cost flow assumptions: FIFO (stands for first-in, first-out), LIFO (stands for last-in, first-out) and WAVG (stands for weighted – average). In this article, I just want to focus on FIFO and LIFO. Let's review these concepts:FIFO means that the oldest inventory items are recorded as sold first but do not necessarily mean that the exact newest physical object has been tracked and sold. LIFO on the other hand means the exact opposite, the most recently purchased items are recorded as sold first. For example, a bakery produces 100 cakes on Monday at a cost of $1 each, and 100 more on Tuesday at $1. 25 each. FIFO states that if the bakery sold 100 cakes on Wednesday, the COGS is $1 per one cake (recorded on the income state ment) because that was the cost of each of the first cakes in inventory. The $1. 5 cakes would be allocated to ending inventory (appears on the balance sheet). In contrast, LIFO states that the same bakery would assign $1. 25 per cake to COGS, while the remaining $1 cakes would be used to calculate the value of inventory at the end of the period. Any company can use either FIFO or LIFO to sell their stuffs. If inflation didn't exist, both FIFO and LIFO methods would produce the exact same results. As the example above, when prices are stable, our bakery would be able to produce all of its loafs of bread at $1, and FIFO, LIFO would give us a cost of $1 per one cake.But our economy seems more complicated; prices tend to rise, which means the choice of accounting method can dramatically affect company profit. We can easily see that, if the selling price is increasing day by day, choosing the FIFO method of accounting will have the opposite affect. FIFO will help company gain more profi t. It means the inventory that you sell costs you less than the inventory that you have remaining. Therefore, the choice of FIFO accounting results in lower COGS on the income statement vs.LIFO and a higher inventory valuation on your balance sheet vs. LIFO LIFO isn't a good choice in inflation because the leftover inventory might be extremely old and, perhaps, obsolete. This results in a valuation that is much lower than today's prices. But we can't always use FIFO method because in some special situations, LIFO is the better choice. For instance, in the deflation economy, we should choose LIFO because the price will go down gradually. The newer products we sell first, the better profit we will get.One more reason for companies to consider LIFO is Tax. Because FIFO results in lower COGS on the income statement, it will make higher earnings. But when earnings are higher, taxes are also higher. And when taxes are higher, after-tax earnings become lower. On the other hand, LIFO result s in lower pre-tax earnings (since COGS are higher) and therefore it gets lower taxes and higher after-tax earnings. The process to choose FIFO or LIFO isn't simple at all, it requires the accountants to analysis carefully to give the best choice for any company.

In Search for Excellence - Free Essay Example

Sample details Pages: 8 Words: 2517 Downloads: 1 Date added: 2017/09/14 Category Advertising Essay Did you like this example? In Search of Excellence| A review of the elements and the book. | | | | | 8/30/2010| | Thomas Friedman in his book â€Å"The World is Flat† outlines how the entire world is shrinking and become a close net ball replete with information highways transferring data, ideas and meaningful business information at a pace that was never imagined before. In the same way the concept of â€Å"speed† is conceptually driven in the mind of business leaders by Bill Gates in his famous book. Don’t waste time! Our writers will create an original "In Search for Excellence" essay for you Create order Scores of management books today are being churned out virtually every day and it’s very difficult to judge how impactful they might be for the time they represent. What works for today has often been seen to be redundant the next time. In Search of Excellence, a revolutionary book by Tom Peters and Robert Waterman, published in 1982, changed the way business looked at itself for that decade and also became the reference point of debates, business ideas and strategies even till date. Even though critics have labeled the book as being â€Å"deficient in Theories† and lacking is strong models that come out of theories, it nevertheless has impacted business worldwide to change the way they function. The Book The Book was fallout of a project conducted by McKinsey in the year 1972. There were two projects first and major one, the Business Strategy Project, was allocated to top consultants at McKinseys New York corporate HQ and was given star billing and later was branded as a total failure. The second weak-sister project concerned Organization structure and people. The Organization project was seen as less important, and was allocated to Peters and Waterman at San Francisco. Peter went berserk on this project and travelled the entire globe talking to CEO’s, business entrepreneurs, Consultants on business and Teams with no aim to chart out a â€Å"business model or a plan. What culminated after this was a mammoth 700 page presentation which was later pruned down to produce the eight themes. The platform for the book was however adopted from McKinsey 7-S Model Elements as shown below:- The Eight Themes 1. A Bias for Action: The name of the title clearly gives an indication that the ultimate goal of an organization is about the results. The effort is impo rtant but unless results are seen, the effort is rendered futile. The methodology any organization can opt for is to enable a platform of seamless information exchange. This will ensure that communication permeates the very fabric of an organizational setup and this can be achieved only if the communication line and processes are flexible and open. The main reason being that such a setup of built in flexibility ensures quick transmission, interpretation, analysis of information and break up of those information into action points. The basis of such a platform is simple. The almost trivial experiment task force, small groups, temporary structure etc all lead to action orientation. Management needs to get out of the office and out and about to communicate with the people of the organization. E. g. of such can be the introduction of the IBM’s System 360 or a 3 day ad hoc task force at Digital. These companies despite their vast size have been able to keep communication simple and have not been transfixed with organizational charts and job descriptions. The basic aim as can be put in words is to ensure experimentation. Companies like Betchel, TI, Digital, Fluor, Emerson, IBM, Dana, Boeing have developed such systems that enables even the most senior leadership employees communicate with people bypassing the obstacle posed by time. 2. Close to the Customer: The main objective of every company is customer focus however not every company can follow it because as Peters and Waterman put it, that despite of all the lip service that is given to market orientation in today’s world, the customer is either ignored or considered as a bloody nuisance. Excellent companies get up close and personal with their customers and one of the company that does that better than anyone else is HP. The main intent of such a company as clearly elaborated by John Doyle is that the best companies are looking at getting the nest product generation into the customer’s premises. Dell does that in terms of it PC BUSINESS where the internet bridges the distance barrier and customers can easily customize their laptops according to their specification. IBM again is referred to in the book as a company that will sell the Brooklyn bridge to its customers like it’s no tomorrow. The other company that did it betters than the most, even better than IBM, was Lanier who ensured that its customers were the closest. Other examples include Disney and McDonalds and have been rated as the best Mass Service providers in America. 3. Autonomy and Entrepreneurship: Tom and Robert have laid emphasis that the very thing that made companies become behemoths in their game of play is being disregarded: innovation. A survey was taken which clearly highlighted that small firms produced about four times more innovation than medium sized firms and about twenty-four times more than large firms. The reason was pointed out as the lack of autonomy in the big firms. Small firms encourage the entrepreneurial spirit among the people while the top notch ones are entangled in bureaucracy. Companies like 3M, IBM, TI, GE, Bristol Meyers were all involved in bootlegging, killing programs and certain degree of madness all around. This fostered â€Å"Champions† to come out and shine in their full glory. The theory of the champions being irrational was given all due credit and became the underlying principle of such companies. The freedom to engage is circuits, groups and function as autonomous bodies with optimum levels of decentralization has fostered Autonomy and led to the spirit of innovation develop around the cultural premises of such organizations. The success of companies such as GE, Wang, J. J, Bloomingdale have more would be champions than their competitors with 3M being the case to be looked into as the forerunner in innovation, entrepreneurial spirit and autonomy to its divisions. The company hence fosters in-house competition, with intense communication and is able to tolerate failure. 4. Productivity through People: The most valuable asset of an organization today are its people. The companies who have valued people have seen to excel more rapidly than those who treat them as second best. The Japanese regarded people as the front- Enders of the business and considered them to be the ones who knew business the best. They keep telling their employees the same and that innovation and improvement must come from Genba (where the action is). IBM’S philosophy of the treating the individual with respect, Delta’s philosophy of â€Å"Family Feeling†, HP’s HP- WAY and â€Å"Management by wandering around† are examples of some HR brands that have gone a lot way to improve productivity of the employees. The philosophy of treating employees as â€Å"workers† have a different affect than when it is when you call them â€Å"people†. The way to ensure productivity however does not involve only devising philosophies, it also means that such philosophies are backed up with heavy people centric management programs, rich systems of monetary and non-monetary benefits and amazing varieties of employee experimental programs. The notable success stories that the book highlights are:- * RMI:- a subsidiary of US Steel and National Distillers. The company was bedridden with low employee performance till they instituted the â€Å"pure corn-a mixture of schmaltzy, sloganeering, communications and a smile at every turn† . This lead to a huge dip in grievance related cases being reported and boosted the morale of the employees. * Hewlett-Packard:- The success of the â€Å"HP way† has won accolades across the world and a lot of companies are now trying to replicate a model for their own concerns. The 1970 recession hit HP in a big way but instead of downsizing the employees accepted a 10% pay cut and weathered the recession with its â€Å"family†. * Other success stories worth mentioning is that of Wal-Mart, Dana, Delta Airlines, McDonalds, IBM but due to words constraint it’s suggested to read the book. . Hands On, Value Driven: In today’s world of cut throat competition, firms are always looking at enhancing their competencies to gain a considerable competitive advantage in the domain/s they function. The emphasis is always on cutting costs, improving efficiency and in the bottom line without giving a thought to the importance to values in an organization. It always pays fo r a company to be value driven because that is the catalyst that will enable the company to leverage its human resources to attain high efficiency quotient. Companies always want to invest in models of budgeting, policies and procedures and organizational structure. These hardlines pail in front of an initiative that lays emphasis on values and culture. The book by Thomas Watson Jr wrote an entire book on Values in IBM called â€Å"A Business and Its Beliefs†. However designing a belief system is just the start as the employees right from the line employee to the CEO must adhere to the belief system else the system collapses with severe ramifications. Companies, great ones that is, are seldom hesitant in propagating their values and belief systems in the public. Frito lays tells stories on services, J;J tells stories on quality and 3M tells stories on Innovation. The best way to gauge if a company is serious about its values is through its annual reports. Great companies make it a point to announce their belief systems in their annual reports for the world to know. Some of the beliefs systems are as follows:- Delta Airlines: â€Å"There is a special relationship between Delta personnel that is rarely found in any firm, generating a team spirit that is evident in the individuals cooperative attitude towards others and pride in a job well done†. Dana: â€Å"The Dana style of management is getting everyone involved working hard to keep things simple. There are no policy manuals, stacked up layers of management†¦Ã¢â‚¬ ¦.. The Dana style isnt complicated or fancy. It thrives on treating people with respect. It involves all Dana people in the life of the company. † Digital: â€Å"Digital believes that the highest degree of interaction in activities needs to be in the area of customer service and support† 6. Stick to the Knitting: Organizations that branch out remaining somewhat close to their primary skill will be more successful than organization that does mindless diversification. The most successful are the ones who are diversified around a single skill- eg the coating and bonding technology at 3M. The reason is simple. Organizations in the course of business always focus on their core competencies and the product line is based on the platform of core competency. The organization is hence able to leverage that process into designing products that have a high degree of product differentiation however an organization cannot have diversified core competencies because there is only so much to do and so much to specialize on. Mobil once attempted to diversify into retailing by acquiring Marcor and the result was a total disaster. If we look at certain companies and how they have stuck to the concept of â€Å"Knitting† we observe certain stories mound up. Boeing:- Observers, notes The Wall Street Journal, say Boeings strength comes from its almost singular devotion to the commercial airline market where it derives almost 90% of its revenue. â€Å"The other guys are too busy chasing military bucks, says one airline official. â€Å"At Boeing the airlines come first†. Fluor: Chairman Bob Fluor comments, We cant be everything to all people. Wal-Mart:- Wal-Marts extraordinary record of growth has come from an overpowering niche strategy. It has stayed in a dozen states. Sticking to what it knows best, if overpowers better financed and more deeply experienced organizations such as K Mart in its chosen area. Deere: Deeres president, Robert Hanson, states: Were sticking to the customers we know. Forbes adds: For years Deere has outperformed its archrival, International Harvester. Ha- allegiance was divided between its truck business and farm Machinery. Deere, by contrast, knew what its business was, who customers were, and what they wanted. Amoco:- The Wall Street Journal contrasts the successful straits of Amoco with its competitors: The wisdom guiding the mammoth oil acquisitions is that its cheaper to buy someone elses reserves than to develop them internally. But at Standard Oil Co. (Indiana), we dont believe that, not for ourselves, tea chairman John Swearingen. (Source: In search of Excellence by Tom Peters and Robert H Waterman) 7. Simple Form, Lean Staff: The size of the company is directly related to the level of complexity of the system, processes and the organizational structure. As the company grows, it adds to it other smaller companies, subsidiaries and complex processes in order to achieve perfect synergy between processes. The key to successful companies is however to ensure that as they grow, the process become simpler. This is a tough nut to crack and companies will dismiss it out rightly. The biggest enemy of the organisation, according to the author is â€Å"Matrix† structure and the only way to achieve simplicity is through divisional structure or Product based structure. The above mentioned structure with a tinge of flexibility proves to be the perfect recipe for organizations today. Companies like Frito lays, Kodak have achieved a lot by following such a platform and so is Johnson ; Johnson. 8. Simultaneous loose-tight properties: The last of the eight elements calls in for the existence of a loose-tight Model which can be translated to be the coexistence of the firms central direction and individuals autonomy. Companies that are loose- tight may be rigidly controlled, but they still foster entrepreneurship and innovation within the ranks. Some of the most exceptional companies like 3M, etc have the most tightly knit models where customer Focus, Customer service and Quality cannot be compromised but at the same time the Model also allows its people to be flexible and at the same time, innovative when it comes to operation. Criticism and Conclusion:- The book remains one of the most successful management books of all time. It sold copies by the millions and became the reference point for so many companies and their strategies. However the term used here, â€Å"reference point† bears testimony to the fact that the book was only theoretical and was criticized as lacking in practical Implications. We have little evidence that it changed corporate practices and produced substantive gains. The other main argument about the validity of the elements is that there exists no empirical evidence on the research done to show the objectivity of the claims and the conclusions. The choice of the companies branded excellent was also questionable as 1/3rd of the excellent companies were in financial difficulties after 5 years of publishing of the survey result. In an article in Fast Company, cited below, Peters remarked that the criticism that If these companies are so excellent, Peters, then why are they doing so badly now, in his opinion pretty much misses the point†. By Sani Sharsar 2010HR047