Practical Criticism on the Tamer and Hawk poem Essay

Tom Gunn’s Tamer and Hawk is an extended metaphor depicting a powerful, strong, almighty, wild bird of prey (a metaphor for Gunn) being controlled by a seemingly inferior body (a human) – his true love. It depicts an image of a bird and its master (with the use of indirect personification). It tells a story of Gunn’s adoration of his ‘Tamer’ and his strong desire to entice his love. It is an effective metaphor because as the poem continues the danger and violence becomes more prominent, especially at the end of the poem. There are three main theme to the poem; love (â€Å"To fly for you and show†), loyalty (â€Å"For you I fear to lose†) and devotion (â€Å"You seeled me with your love†). The first stanza explains how the Hawk is happy to be domesticated by this person, as he expresses no objection to his situation. He even wants to show off his capabilities in a performance to his Tamer in the hope of impressing him. Gunn idolis es his Tamer by portraying him as kind (â€Å"But gentled at your hands†) and being gently powerful (â€Å"I thought I was so tough†) – with the emphases on the second ‘I’ trying to show the Tamer is more powerful than himself, as well as the quotation â€Å"Upon your wrist† which depicts the Tamer as somewhat of a godly figure who is in control of another life. Also, the quick rhyme scheme: A, B, A, C, C, B, along with the lack of any punctuation and the fast rhythm of the stanza (without any assonance or alliteration or sibilance), due to the Iambic trimeter, emphasises the Hawk’s effort he is putting into his performance, and hence trying to impress his Tamer. This is cemented by Gunn’s use of the phrase â€Å"Cannot be quick enough† which implies that his pace is still not enough to please his lover. The second stanza could be seen as a continuation of the first stanza, the themes are interrelating and also the ideas are common. It evinces the Hawk still not being able to fly away, as he is too in love with his Tamer that whenever they are apart, as soon as he calls him back he returns as fast as he can. It is evidence of how he is becoming so subservient to his Tamer (â€Å"I am no longer free†). Additionally, this quotation implies that the Hawk is in the process of being tamed, which means that there are st ill some wild aspects of his nature. This links to the quotation â€Å"You but half-civilise† which leads to hazardous consequences. One also gets the sense that the Hawk has some desires to be released – showing his wild core aspects, by the use of regular polysyllabic words,  with possible double meanings – â€Å"no longer free,† â€Å"seeled,† â€Å"blind,† â€Å"hooded.† The fact that the majority of these words are polysyllabic could be intended to extend the length of the word in order to express his pain, suffering and anguish. Stanza three explains how the Hawk has now broken free and has the opportunity to open his wings and explore, however, there is one major drawback. He cannot release the thought of his love, the Tamer, which is constantly on his mind (â€Å"In my possessive thought, Of catcher and of caught†). Additionally, in the first line of this stanza the word â€Å"formerly† links back with the idea that he is putting on his best show in order to try and impress his love, continuing the themes of devotion, loyalty and love, and also dete rmination and fortitude. Despite the clues embedded within the poem, it is the final stanza that is the climax of the poem. There are several integral parts to the poem in this stanza. The general picture of the stanza is that the Hawk is willing to go to the very extremes if it means not losing his love. The phrase â€Å"half-civilised† proves that the Hawk still contains his wild instincts and nature, as he is still half wild, however, this is no excuse for what the Hawk plans to do to his Tamer – Kill him. â€Å"For you I fear to lose, I lose to keep, and choose Tamer as prey† explains the Hawk’s plan. It may not be very evident but it does illustrate what the Hawk is willing to do, in order for him not to lose his Tamer. The Hawk obviously longs for the Tamer, however, he might long for him slightly too much because it could be on a parallel with how much a Hawk longs for its prey. One could form the opinion that what the Hawk is a metaphor for is monomaniacal as he is willing to kill his love in order to keep it. â€Å"I lose to keep† is a paradox because the two words in juxtaposition are opposites, contradicting each other, creating an antithesis. It is incomprehensible that one must lose something in order to keep and preserve it. This is the most extreme example of devotion. Generally, the fact that all of the stanzas end in an abrupt fashion, with a four syllable line instead of the previous six syllables, could be interpreted, by the reader, as the Hawk’s realisation that his Tamer is not returning his love and reveals the Hawk’s desperation and disappointment when he is rejected his ultimate wish. The extended metaphor is a very good and effective one because it gives very clear images of all of the scenes created by Gunn and also it is appropriate because the relationship is so  domineering, possessive and un-natural.

How to Start Writing a Novel 3 Key Elements a Novel Needs to Succeed

How to Start Writing a Novel 3 Key Elements a Novel Needs to Succeed How to Start Writing a Novel: 3 Key Elements a Novel Needs to Succeed Want to write a compelling, dramatic story?One that draws readers in, takes them on a roller-coaster ride of emotions and thrills,  then leaves them hungry for you to publish your next book, and your next, and your next?If so, then I have good news:With the right understanding of story structure, I believe anyone is capable of writing an amazing story.Yes, that includes you.And the key to making this process as easy and natural as possible is to start every novel with a good story foundation.This is where most new writers struggle. Either they have trouble getting their story off the ground, or they can get it off the ground, but it nosedives partway through the book.Either way, the cause is the same: they didn’t start their book from a good story foundation.In other words, they were missing one or more of thethree critical elements that every novel needs to succeed. I call these foundational elements, â€Å"The Story Foundation Trifecta.†Let’s talk about itNOT E: We cover everything in this blog post and much more about the writing, marketing, and publishing process in our VIP Fiction Self-Publishing Program. Learn more about it hereHow to Start Writing a Novel for BeginnersIf youre new to the world of writing, its really easy to get overwhelmed. Its normal to feel that way. Youve never done this before and its a major task to learn how to write a book.What advice do you listen to?How will you even sift through all of the ideas you have?What steps do you actually need to take to start writing a novel?The best part about being a beginner is that you  can  only  make  progress. Theres really nowhere else for you to go but up.The tricky thing, however, is knowing how to get started. After all, that step is the most important, but also the most difficult.These are among the first things you have to do in order to start writing a book as a beginner:#1 Choose a book idea to write aboutIf youre ready to write a book, chances are you hav e more than a single idea in mind thats just how the minds of creatives like yourself work.But how do you choose which to write and which to save for later?The good news is that any and all of your book ideas can get written, its just a matter of choosing which goes first.These are a few questions I like to ask myself when it comes to deciding which idea to start next:Which do you find yourself thinking about most often?Which has a theme/message that means the most to you?Which do you have the most content developed for?Which will be the fastest to write?Once you have an idea in mind that fulfills these questions, youll know that that is the one to write about.Essentailly, in order to choose a book idea, think about which one youre most passionate and excited about. #2 Start your mindmap and outlineOutlining is necessary no matter what type of book youre reading. Even if you think youre the type to write by the seat of your pants, an outline of some sort will come in handy.Even St ephen King has the end of his stories in mind and a few plot points along the way, and he self-identifies as a pantzer, or someone who writes by the seat of ones pants.Now this does NOT mean you have to go through every single part of your story and create a step-by-step outline of everything that will happen.You can do that, but you don’t have to.Generally speaking, there are two kinds of writers out there:Plotters (like James Patterson)Pantzers (like Stephen King)Plotters are people who like to plot their stories in advance, while pantzers are people who don’t- they â€Å"fly by the seat of their pants,† coming up with their story ideas on the fly.You might think that outlining is only important for plottersbut actually, that’s not the case. EVERY writer needs to come up with at least a basic outline before they start writing.Even Stephen King, the most well-known pantzer out there, has admitted that he writes his stories with an end in mind.Knowing whe re your story is going can help you develop the plot to be more complex, exciting, and allow you to hide foreshadowing within the book.This will help you craft your twists to be even harder to see coming something all bookworms love.We have complete guides for learning how to fill out a mindmap and then complete an outline based on it. Check those out before moving on to the nexts steps because its essential to have those details done first.#3 Consider how long you want your book to beThis is also the stage in which you figure out if youll be writing a standalone (a single book) or a series (2 + novels of the same storyline).But first, how long do you want this book to be? Some authors will tell you to just write as much as is needed, but its often a good idea to know your baseline so you can stay on track.This is a table of the average word count for different types of novels to help you get an idea for what to shoot for:Type of WritingWord CountPages in a Typical BookExampleShor t story100 - 15,0001 - 24 pages"The Gift of the Magi" by O. HenryNovella30,000 - 60,000100 - 200 pages"A Clockwork Orange" by Anthony BurgessNovel60,000 - 100,000200 - 350 pages"Harry Potter and the Sorcerer's Stone": by JK RowlingEpic Novel120,00 - 220,000+400 - 750+ pages"Game of Thrones" by George R.R. MartinOnce you have an idea as to how long you want your book to be, you can better plan out each chapters length and formulate a writing schedule that will allow you to make real progress.How to Start Writing a Novel with the Story Foundation TrifectaFirst off, what IS the Story Foundation Trifecta?It’s a combination of  three things:An interesting premiseA sympathetic heroA clear compelling â€Å"A-story†As you’re about to learn, these are the most critical and fundamental pieces to any successful story. As long as you have these three things in place, your story is bound to be engaging and entertaining.In the rest of this post, I’ll explain what th ese things are and how you can improve these elements in your story idea. And to help you understand, I’ll be using examples from well-known stories such as The Hunger Games, The Matrix, and my own series GoneGod World.Foundation #1: An Interesting PremiseYour premise is the foundation of your plot. The collection of situations or presuppositions that make up your story world.That sounds complicated, so let’s put it in simpler terms:Your premise consists of 2-3 seemingly unconnected ideas that have been meshed together to make something truly unique.If you analyze really popular stories like The Hunger Games and The Matrix, you’ll realize they have great premises. And that’s a big part of the reason why they were so successful.So how do you come up with an awesome premise of your own?One common method is to use the â€Å"What If† technique. Here’s how that might look using The Hunger Games as an example:The Hunger Games: What if, sometime in the future, there is a society which demands children must fight to the death once a year?Immediately, the premise opens up a hundred other questions that your story may or may not answer. What happened to create this world and contest? Why children? What happens to the victors? Your story may not answer all of these questions, and certainly Suzanne Collins – the author of The Hunger Games – doesn’t answer all of them.See how that works? You take a few different ideas and combine them. See how they might fit together.In this case the premise is using the familiar idea of a gladiator storybut it’s mish-mashing that concept by having the gladiators be children.Then when you throw in a couple extra elements, likeSetting the story in the futureIncluding a love-triangle with the main characterHaving a power struggle behind the scenes only the audience knows aboutyou end up with a really great premise for a story.Here’s another example:The Matrix: What if reality isn’t what we think it is, and in fact we’re all connected to computers as human batteries for the robot world?Here we’re taking the idea â€Å"reality isn’t what you think it is† and mashing it together with â€Å"we’re human batteries connected to computers.†These are cool ideas on their own. But when you put them together, they become something really fascinating. With a premise like this, is it any wonder why The Matrix was so successful?And here’s one more example, from my series of books:GoneGod World: What if all the gods are gone, and when they leave they force all their denizens to go to earth?Here I’ve combined the ideas of â€Å"divine creatures† and â€Å"refugees† to create a unique story premise out oftwo familiar ideas.In this story, every sort of magical creature you can think of- dragons, faeries, etc.- is forced to become a refugee on earth. As you can imagine, this opens up all kinds of possibilities for interesting storylines and conflicts.So that’s foundation #1 of the Story Foundation Trifecta: create an interesting premise. Now it’s your turn:How to Start Writing a Book Action Step:Take a look at your favorite stories and identify their premise. Turn those premises into â€Å"What if† statements.Bonus: Among the premises that you have identified, see if you can alter them slightly to turn them into something completely unique.Challenge: Create 3 to 5 premise statements of your own, statements that ultimately create world, you’d love to write in.You’ll be surprised at how quickly you start cranking out really unique story premises.Foundation #2: A Sympathetic HeroFoundation #1 focuses on your plot. It’s a big-picture statement of what happens in your story.But remember, stories don’t just happen by themselves. They happen to characters- to people. To human beings. (And sometimes, to elves and aliens.)At the heart of every story is a hero who strives to meet an important goal. And the more your audience can understand and identify with that hero, the more likely they are to become engrossed by your story.Now when you’re creating your hero, the  three  most important things to figure out are your hero’s:Key traitsOuter journeyInner journeyâ€Å"Key traits† refer to your character’s distinguishing features. Is your hero:Brave?Intelligent?Beautiful?Charming?Underhanded?Strong as an ox?Your character’s journey refers to the challenges they will be forced to overcome throughout the story. And we break that journey up into inner and outer journeys.A few examples:The Hunger Games: Katniss’s outer journey is to survive the games. Her inner journey is to mature as an individual, to let other people in, and to learn to accept help from others.The Matrix: Neo’s outer journey is to defeat Agent Smith and the robot forces enslaving humanity in side the Matrix. His inner journey is to believe in himself and accept that he’s the only one capable of saving the human race.Make sense? Great. Now go figure out who your hero is, give them a few key traits, and most importantly decide on their inner and outer journey. Then when you’ve completed that, you’re ready to move forFoundation #3: A Clear Compelling â€Å"A-Story†Once you know your story’s premise and have identified your hero, your next step is to use those 2 elements to create your â€Å"A-story.†Loosely defined, your A-story is the main storyline in your novel. It’s the one story we need to see resolved in order for us to put down your book and feel satisfied at the end.Your book can have multiple storylines- maybe you have a romance subplot, for example- but your A-story is the main story. The big problem that gets resolved at the end. The big problem that gets resolved at the end.In most cases, your A-story is going t o be the same as your hero’s outer journey. In The Hunger Games, for example, the A-story is Katniss’ trial to survive the games.But your A-story can also tie into your hero’s inner journey. In The Matrix, the A-story deals in part with Neo’s struggle to believe in himself and become â€Å"the one.†Here are some common A-stories for different genres to think about when you start writing a book:Sci-fi: Repel the alien invasionAction: Get revenge on the bad guysRomance: Finally succumb to the love of your lifeIt’s important to know your A-story. This is the storyline that you need to focus on, to keep coming back to. This is the major conflict of your story, so don’t lose sight of it.Exercise: Identifytwo or three unique A-stories that fit could each premise. Spend a few minutes contemplating how the premise and the A-story work together. (And also relish is how your A-story is better than the original 😊.)Bonus: Could you alter o ne of the premises to fit with your own unique A-story? If so, you very well may have the a kickass story on your hands!Challenge: Now that you have defined your premise in step one, identify 2-3A-stories that could work within that premise statement.How to Start Writing a Book Action Step:Identify two or three unique A-stories that fit could each premise. Spend a few minutes contemplating how the premise and the A-story work together. (And also relish is how your A-story is better than the original)Bonus: Could you alter one of the premises to fit with your own unique A-story? If so, you very well may have the a kickass story on your hands!Challenge: Now that you have defined your premise in step one, identify 2-3 A-stories that could work within that premise statement.You Know Your A-StoryNow, What’s Next?OK, so you’ve gone through the Story Foundation Trifecta and figured out your premise, hero, and A-story. What should you do next?Sign up for your free training to guide you through this process with more detailIts not enough to just read about it. What you need is someone whos done it before to take you through this process step by step.When it comes to fiction, those with experience are those who thrive and we should all learn from someone who know what theyre doing because if we can bypass all the mess of starting to write a book, we should.

Hammurabis Code and the Babylonian Economy Essay

Hammurabis Code and the Babylonian Economy - Essay Example The Code showed the importance of agriculture as the major livelihood of the citizens. It should be noted that various laws mention major crops such as corn, grains, and wool. The heavy punishment to be administered to anyone stealing and causing poor harvest indicates the importance of these commodities. It is also notable that the agricultural economy of Babylon is supported by quite complicated infrastructures to ensure a good harvest. The Hammurabi's Code mentions the presence of dams and dikes which prevents flooding agricultural areas. Animal husbandry is another major livelihood during the Babylonian Empire. It should be noted that the Code set out provisions regarding the robbery of major livestock. Within that civilization, it is remarkable how the citizens were able to raise a number of animals such as cattle, sheep, ass, pig, or goat. The importance of animal husbandry in the economy cannot be overestimated. For an individual steal any of the aforementioned animals and has nothing to pay for it, he will need to give his life as a payment. Though the above two industries represents the two major activities in the Babylonian economy, it should be noted that the civilization also features extensive trading network,

Leadership Style Paper Grading Criteria Research

Leadership Style Grading Criteria - Research Paper Example One approach to successful leadership is aligning with the contingency style and theory of leadership. In this theory the leaders are flexible enough to continually adapt the styles of leadership in response to situational changes. Contingency theory of leadership envisages a kind of leader with behaviors that range between being authoritative & persuasive and vary according to needs of the present time as well as possibilities for the future. A manager in the field of nursing for instance may be compelled to be authoritarian in an emergency situation like when handling a patient with cardiac arrest. The same leader faced with the challenge of encouraging team members to take care of patients having multiple system failures may opt to employ persuasion. The leader can delegate some duties and decisions to competent followers e.g. when it comes to completion of patient forms. An effective style of leadership for a nurse is one which aligns well with the work environment, tasks at hand and personalities of individuals involved in various situations. President Barack Obama of the United States is one of the most successful world political leaders of the modern times. He is one person who is very effective in communication and articulation of issues facing America. He is firm and decisive when it comes to decision making for instance when faced with issues of terrorism he has consistently remained firm and focused to ensuring the security of Americans. As president of America Obama is capable of assessing situations and making independent decisions, involving followers to collect information for decision making purposes and persuading followers to implement the decisions. Obama as a leader employs consultation widely to get advice, make decisions and inform, joins groups to seek opinions in order to indecently make sound decisions. He such an aggressive leader who would delegate duties to followers so as to come up with solutions and actively

Streetcar Named Desire Essay Example | Topics and Well Written Essays - 500 words

Streetcar Named Desire - Essay Example He led life his own way. He was a man who was keen to protect his sexual relationship with his wife and this is one of the reasons why Blanche thought it was important for her to protect her sister from his violent acts. There was sexual tension between Blanche and Stanley from the moment they first meet. In one scene Stella is out of the picture (in the bathroom washing her face) the first time Blanche encounters Stanley. They’re alone together. He takes off his shirt on the grounds that he wants to be â€Å"comfortable.† While Blanche pretends to be ok with this, we know later that such informalities in fact make her feel uncomfortable. In another scene when Stanley rifles through the personal things in Blanche’s trunk, it’s as though he’s violating her as well. The big â€Å"Stelll-ahhhhh!!!† scene is as much about Blanche’s discomfort with Stanley’s destructive sexuality as it is fear for her sister. She’s horrified that Stella goes back downstairs in order to make love with Stanley. She even tried to persuade Stella but she chose brutish love over a better life. Her love for Stanley gave him the advantage over his enemy. Blanches jealousy is also quite noticeable in many scenes. Since she is dealing with the loss of her husband, Belle Reve, she envies her sister’s happiness and protection and how she has sexual freedom. In Scene Four Blanche says: â€Å"What such a man has to offer is animal force. But the only way to live with such a man is to go to bed with him! And that’s your job not mine!† It seems unfeasible for Blanche to relate a man in a non-sexual way, even those men who would be considered inappropriate for her i.e. her brother-in-law, Stanley. Even so, she was always quite eager to get a hold of Stanley’s attention and receive compliments about her physical appearance from him. After their first

What Feminism and Women's Studies Calls for and Performs Essay

What Feminism and Women's Studies Calls for and Performs - Essay Example This paper will focus on identifying significant ideas associated with feminism and women’s studies, and some of the significant role they play in the society. One the significant role played by feminism and women’s studies is to contribute to development of feminist movements and academic studies regarding construction of gender that facilitate harmony in the society. Besides, feminism and women’s studies are applied in gathering ideas that can question various cliches regarding gender, race and religion, which are sometimes considered nature, though they are established through social interactions. In addition, feminism and women’s studies has enable recognition of the effort that her been made by women in the resent years in order to realize the stature of feminism in the present day. Feminism and women’s studies takes interdisciplinary nature, which leads to affirmations of diversity in the perceptions by people who study them. Moreover, feminis m and women’s studies offers a basis of developing strategic discussions, feminist praxis, and for making significant interrelationships across various boundaries that are conventionally conceived. Feminism and women’s studies has facilitated flexibility, and a basis of questioning various notions regarding human assumptions regarding gender and relations. Feminism and women’s studies plays a vital role in encouraging members of the society in developing skills that can enable them think critically and sensitive about issues relating to gender. On the other hand, these studies offer students a critical awareness regarding the operations of gender and the way they operate in various contexts such as institutional, cultural and social. Feminism and women’s studies offers an introduction of critical gender theories that forms a functioning in demanding intellectual environment (Levin, 12). These studies take a vital role of introducing history, feminist theo ries and criticism, which are bases on critical theoretical framework applied in developing vital perceptions and knowledge about gender inequalities. Feminism and women’s studies strengthens ability to discuss and writer about feministic criticism with a high level of coherence, logic, and analytics (Kesler and Sameh, 185). Apparently, feminism and women’s studies requires understanding of feminist critiques, which are applied in making informed judgments and strengthening the society, building public policy and reconstructing sexist institutions. There is need to understand the impact of feminist perception and criticism, and the challenges that they have pose do conventional disciplines of liberal arts. Feminism and women’s studies has led to identification of women’s contribution to knowledge that was overlooked in the past. Feminism and women’s studies serve as vital sources for substantial writing regarding issues that involve women’s race and social classes (Kesler and Sameh, 186). Therefore, this creates familiarity with literature on women’s studies and awareness of significance of vitality of the journals, which involves frequency of publishing articles in Feminist Studies. However, understanding ideas in feminism and women’s studies, it is important to collaborate with in new generations of feminist scholars, activists’ artists, and creative writers. In addition, there is need for

Hypertension Case Study Nursing

Hypertension Case Study Nursing 1) CASE SUMMARY Mr. MS is a 58-year-old Malay male who was previously diagnosed with hypertension, gout and triple vessel ischemic heart disease. He first presented with chest pain in March 2010 where he was diagnosed with ischemic heart disease. He was unable to complete an exercise stress test and an angiogram done in Hospital Sultanah Aminah found him to have triple vessel disease. He was told angioplasty was not possible due to the severity of the blocks and was counseled for CABG but he was not keen. Meanwhile, he has had angina attacks 2 to 3 times per week every week since his initial diagnosis for the last 3 months, usually relieved by sublingual GTN and was currently admitted for the 4th time for chest pain not relieved by GTN. ECG done 2 hours after onset of chest pain showed ST depression of 2mm at leads I, aVL, V3 V6 and left axis deviation with no Q waves. Trop T was positive (2.75 ng/ml) at 4 hours after onset and other cardiac enzymes were also raised significantly. He was diagnosed with NSTEMI and treated with aspirin 300mg, IV morphine 2.5 mg, sublingual GTN 3 tablets and subcutaneous clexane 60mg BD for 3 days as well as continuing his current medication regime of simvastatin, metoprolol, cardiprin, ISDN, amlodipine and GTN. Following admission, he was well in the ward with no recurrence of chest pain and did not develop any new complaints. He was discharged after 3 days of inpatient treatment with instructions to attend his follow-up appointment at the cardio clinic in HSAJB on the 16th of June 2010 to make an appointment for surgery. Following this episode of chest pain, which he says is the worst so far, he is now quite keen for CABG. PATIENTS DETAILS I/C NUMBER: 510831015263 AGE: 58 SEX: Male DATE OF ADMISSION: 3/6/2010 R/N: 1348445 2) CLINICAL HISTORY Chief Complaint Chest pain for 1 day. History of Present Illness Mr. MS is a 58-year-old Malay male who was previously diagnosed with gout, hypertension and ischemic heart disease with triple vessel disease. He was awoken from sleep at about 10pm due to a central chest pain of sudden onset. He described the character of the pain as crushing in nature and radiated to his neck. This episode of chest pain was the most severe since he was first diagnosed with ischemic heart disease. The pain was associated with profuse sweating, body weakness and was not relieved by rest. However, it was relieved by sublingual GTN, of which he has a supply of. His discomfort was made worst by exertion so he lay in bed to recover. Despite this, he had another episode of chest pain 30 minutes later. He took the sublingual GTN again but this time, the pain did not resolve. He was then brought to the emergency department of Hospital Batu Pahat by his son. This is Mr. MSs fourth admission for chest pain since March 2010. Since his diagnosis of ischemic heart disease in March, he has experience angina attacks two to three times per week, especially on exertion such as when straining while passing motion. During these attacks, he uses sublingual GTN to relieve his symptoms and normally feels much better after that. He only comes to the hospital when GTN does not work to relieve his symptoms. Systemic Review Mr. MS does not experience symptoms such as palpitations, dizziness, headache, nausea, vomiting, orthopnoea, paroxysmal nocturnal dyspnoea, epigastric pain, shortness of breath, fever, and had no syncopal episodes. He also does not have loss of appetite or loss of weight. Bowel and urinary habits are normal. His sleep has not been affected until this current episode whereby he was awoken by the chest pain. Past Medical History Mr. MS was diagnosed with hypertension 6 years ago when he had an episode of headache. He has been on medication since and was on regular follow-up with KK Rengit. He was diagnosed with gout 5 years ago when he had a left big toe swelling which resolved after some medication. He is not on long term medication for gout. Mr. MS was admitted for the first time 5 years ago in 2005 when he had bilateral renal calculi. He was subsequently referred to Hospital Sultanah Aminah for further management of this problem and it has since resolved and does not have follow-up anymore. Mr. MS was diagnosed with ischemic heart disease in March 2010 when he presented with chest pain for the first time. Following his recovery, he underwent a stress test in Hospital Batu Pahat but according to him, was unable to complete the procedure due to chest discomfort. He was referred to the cardiology unit in Hospital Sultanah Aminah for further management where an angiogram was performed and he was told to have triple vessel disease. He was also told that angioplasty was not possible due to the severity of the blocks. He was recommended to have Coronary Artery Bypass Grafting (CABG) but as of yet, no appointment has been made as he was still unsure of going through with the procedure. Following this episode of chest pain, Mr. MS has decided that going for the CABG is the only thing that will keep him alive. His current medications include: Tab Simvastatin 20mg OD Tab Metoprolol 75mg BD Tab Cardiprin 100mg OD Tab Isosorbide Dinitrate (ISDN) 5mg TDS Tab Amlodipine 10mg OD Sublingual Glyceryl Trinitrate (GTN) PRN He is compliant to his medication regime. Mr. MS is not known to have diabetes or hyperlipidemia. He also does not have any known food or drug allergies. Family History Mr. MS is the 3rd of 9 siblings. His father had hypertension and passed away a long time ago due to unknown causes. His mother and other siblings are healthy. None of them have hypertension, diabetes, ischemic heart disease or malignancy. Social History He lives in a kampung in Rengit with his wife and 5 children. Mr. MS does not smoke nor consume alcohol. He works in a palm oil plantation. The distance from his house to Hospital Batu Pahat is about half an hour. On further enquiry, Mr. MS says that the cost of the CABG is about RM1000, which he can afford. 3) FINDINGS ON CLINICAL EXAMINATION (Mr. MS was examined by me 9 hours after onset of chest pain) Mr. MS was alert, conscious, and communicative. He was not in obvious pain or respiratory distress. He was lying down comfortably on his bed. There were no tendon xanthomata, xanthelasma, pallor, corneal arcus or pedal edema. His JVP was not raised. His clinical parameters are: Blood Pressure : 158/94 mmHg Heart Rate : 94 beats per minute. Regular rhythm Respiratory Rate : 20 breaths per minute Temperature : 37Â °C SpO2 : 97% under room air On examination of the precordium, the apex beat was located at the 5th intercostal space on the midclavicular line and was normal in character. Parasternal heave was not felt and there were no thrills. First and second heart sounds were heard. There were no murmurs or added heart sounds. On examination of the chest, there was no deformity and chest expansion was equal on both sides. Percussion and tactile vocal fremitus was normal and equal on both sides. On auscultation, vesicular breath sounds were heard throughout all lung fields with good air entry. There was no wheezing or crepitations heard. On examination of the abdomen, it was soft and non-tender. There were no masses felt. Bowel sounds were heard and normal. 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional Diagnosis Acute myocardial infarction with underlying triple vessel ischemic heart disease and hypertension With a history of diagnosed triple vessel ischemic heart disease with multiple episodes of angina attacks since the initial diagnosis, it is highly likely that Mr. MS is presenting with an acute coronary event and this should be a priority until proven otherwise. This is evidenced by the presentation of central, crushing chest pain of sudden onset that radiated to the neck and associated with profuse sweating and body weakness which is classical of a myocardial infarction. Mr. MS will require immediate investigations such as an electrocardiogram and cardiac enzymes to differentiate the acute coronary syndromes so that the appropriate management may be instituted for him e.g. if he has an ST-segment elevation myocardial infarction (STEMI), he will require myocardium-saving thrombolytic therapy to disrupt the ischemic event. As Mr. MS did not present with features such as acute shortness of breath, loss of consciousness and severe palpitations, it seems that he does not have complicati ons of acute myocardial infarction but these developments should be watched out for throughout his admission as complications may arise later. Differential Diagnosis Pulmonary embolism Pulmonary embolism is a possibility that can be considered when a patient presents with an acute chest pain that is accompanied by shortness of breath, hemoptysis, tachypnea, fever and even cyanosis and collapse in severe cases. Furthermore, the chest pain is of a pleuritic nature, of which it is worsened on breathing, and a pleural rub can be heard on auscultation of the chest. However, Mr. MS did not present in such a way. At the same time, Mr. MS did not have risk factors such as a deep vein thrombosis, prolonged immobilization or recent surgery. It is still highly likely that Mr. MS has suffered an acute myocardial infarction, and an ECG would help to differentiate between the two as pulmonary embolism might show the classic S1Q3T3 pattern of right axis deviation or right bundle branch block. Either way, the diagnosis should be made quickly so treatment may be instituted before his condition becomes worse or complications develop. Aortic dissection Aortic dissection presents as an acute onset chest pain that is tearing in nature, and often radiates to the back. It is often confused with myocardial infarction due to its presentation but differences include the lack of profuse sweating, signs of heart pump dysfunction and a normal ECG. Risk factors are usually uncontrolled hypertension, connective tissue disorders or chest trauma. Mr. MS has hypertension, but is under control, and does not have the other risk factors. A diagnosis of myocardial infarction should be the priority as thrombolytic therapy is vital, but if there is any reason to doubt that diagnosis, then further investigations should be performed. 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Acute chest pain Mr. MS has acute chest pain with features very suggestive of a classical picture of myocardial infarction as he presents with crushing central chest pain that radiates to the neck and associated with profuse sweating and weakness. Given that he is known to have triple vessel ischemic heart disease and that he has suffered many angina attacks since his initial diagnosis, it is highly likely that he is having an acute myocardial infarction. Without further a due, he needs an electrocardiogram (ECG) and cardiac enzymes tested to distinguish between the different acute coronary syndromes so that the appropriate treatment protocols may be initiated for him as soon as possible to disrupt the ongoing ischemia. As Mr. MS is having severe chest pain that may overstimulate his sympathetic system and cause further ischemia, he will require immediate supportive therapy such as effective pain medication and oxygen therapy. 2. Triple vessel ischemic heart disease awaiting CABG Mr. MS was diagnosed with triple vessel ischemic heart disease when he first presented with chest pain in March 2010 and has since experienced many episodes of angina. Given his diagnosis and disease pattern, he is at a very high risk of developing a severe acute coronary event that may prove fatal if the infarction is too extensive or if complications develop. As percutaneous revascularization with a stent or balloon was not possible for him, he will require a CABG to both relieve his symptoms and reduce his mortality risks in the long term. He was unsure of going ahead with the operation previously, therefore no appointment date was given for surgery. However, now that he has changed his mind, every effort should be made by both the doctors in charge of him here in Hospital Batu Pahat and in the cardiology unit of Hospital Sultanah Aminah to arrange for his surgery as soon as possible, given the circumstances of his condition. 3. Compliance to medication Mr. MS is on several medications for his triple vessel ischemic heart disease and will require revascularization surgery soon in order to decrease his mortality risks. However, waiting for a CABG in the government setting may take some time, even under dire circumstances due to the nature of the system. Therefore, it is extremely crucial that Mr. MS is compliant to his medication regime while awaiting a CABG to prevent another episode of infarction. He should be counseled to fully understand this and the situation of his ischemic heart disease. It is also the responsibility of his doctors to ensure that he is taking the right combination of medications with the aim to prevent another acute cardiac event. Meanwhile, a sufficient supply of sublingual GTN should be provided for Mr. MS in cases of angina attacks at home. He should come to the hospital immediately if GTN fails to relieve his symptoms. 4. Regular screening for comorbid diseases Mr. MS has not been diagnosed with diabetes or hyperlipidemia previously but these diseases are strong risk factors for the long term implications of his ischemic heart disease. Therefore, Mr. MS should be screened regularly e.g. twice yearly during his follow-up appointments. Early detection of diabetes is necessary so that treatment can start as soon as detected in order to prevent his ischemic heart disease from becoming worst than it already is. As for his lipid control, if his lipid profile is found to be outside the normal limits, the dosage of his medication can be increased as necessary. Following his CABG, he will need to maintain a healthy lifestyle of a good, well-balanced, low-salt and low-fat diet and regular exercise within his limits. 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1. Electrocardiogram (ECG) To look for any changes that may indicate an ongoing ischemic event, such as ST elevation or depression and T wave inversion in order to support the diagnosis of an acute myocardial infarction so appropriate treatment can be started. Differentiation of ST segment elevation or depression is also crucial in initiating treatment as thrombolytic therapy is only indicated for ST-elevation myocardial infarction. Results: ECG on admission (2 hours after onset) shows sinus rhythm with ST depression at leads I, aVL, V3 V6 with left axis deviation. T wave was present and normal. Interpretation: The ST depression in the leads above indicate an ischemic event at the anterolateral sections of the heart. The lack of ST elevation concludes a diagnosis of either unstable angina or NSTEMI, depending on the levels of cardiac enzymes. There is no sign of old infarction. 2. Cardiac Enzymes To look for elevated levels of cardiac enzymes such as troponin T, creatinine kinase (CK), lactate dehydrogenase (LDH) and aspartate transaminase (AST) that will indicate myocardium ischemia and necrosis. If elevated, a diagnosis of NSTEMI can be made in accordance with the ECG changes. However, cardiac enzymes when done too early after onset may not show any rise in levels 1. This does not mean that necrosis has not taken place and the test should be repeated once more at 6 hours after onset 1. Results: Troponin T (4 hours after onset) 2.75ng/ml ↑ (12 hours after onset) (60 hours after onset) Normal Range (U/L) CK 997 ↑ 263 ↑