Chronic Obstructive Pulmonary Disease Case Study

Chronic Obstructive Pulmonary Disease Case Study CASE STUDY : COPD This piece of work will explore the comprehensively physical examination, differential diagnosis and various diagnostic tests to confirm the disease condition that is CHRONIC OBSTRUCTIVE PULMONARY DISEASE. It will then move further to discover the comprehensive treatment plan and present a argument on an excellent method to treat the disease condition on the basis of current evidenced based studies. The actual name of the patient is replaced with another name so as to retain confidentiality (Dimond, 2002). Mr.X is a 58 year retired office manager came to the emergency ward with his son. He had chief complaints of difficulty in breathing, severe cough, weakness and was feeling discomfort. Patient general appearance shows that he is weak, sitting in high fowlers position, respiring through pursed lips. Suggest that this type of breathing is the indication of emphysema. Pursed lip breathing helps in emitting the air which is trapped in the lungs and limits the force for taking breath (Rik Gosselink, 2003). History taking and proper investigations are the two main components for confirming the disease condition. Complete history is essential to determine the exact etiology of shortness of breath that includes past history of asthmatic attack, family history of asthma, occupational history, present history of smoking, alcohol intake, medication history, episodes of cough whether it is productive or not, presence of any heart problems (Walsh, 2008). COPD develops due to the lack of alpha one antitrypsin hereditary factor. Furthermore the occupational hazards along with genetic factor deteriorate the condition. So detail history collection including all the aspects is significant (Yohannes and Hardy, 2003). History of patient reveals that patient was a chronic smoker from the past 20 years and consume near about twenty cigarettes every day, although patient left smoking 6 months ago his smoking history provides estimation of 20 packs a year. Moreover COPD is more prevalent in patient who consume 20 packs of cigarettes in one year (Georgios et al, 2004). However there are various other diseases that occur due to cigarette smoking such as cancer, heart diseases, pulmonary diseases, influenza, pneumococcal, meningococcal, tuberculosis etc (Arcavi and Benowitz, 2004). Also patient is not able to perform daily activities due to shortness of breath and cough with sputum production. These symptoms are quite common in carcinoma of bronchus, however difficulty in breathing, cough and sputum production are also main clinical symptom of COPD (Pauwels and Rabe, 2004). Moreover, history of the client indicates that plentiful production of sputum for more than three months for two years which shows t he presence of chronic bronchitis (GOLD, 2008). Patient is also not able to sleep during night. Awakening during night which occurs by shortness of breath reveal presence of congestive heart failure or asthma (Price, 2010). Complaints of patient we loss of weight, fatigue, chest tightness due to severe episodes of cough, disturbance in sleep. Dietary history shows that patient is non vegetarian, family history does not provide any significant data. Client having age more than 40 and have sign and symptom such as formation of sputum, difficulty in breathing, history of cigarette smoking and any inhalation of noxious fumes and chances of occurrence of COPD is more at the age above 40 ,therefore patient is believed to have COPD (Vestbo, 2010). Although all the sign and symptom of the client signify that patient is suffering from COPD still functional diagnosis is necessary to confirm the exact diagnosis and proper physical assessment is necessary to confirm the diagnosis (Ferrara, 2011). In high risk cases of COPD proper cardinal sign, body mass index, height and weight of the patient is to be notified as component of assessment (Stockle, 2007). The vital sign of patient are blood pressure:124/76mmHg, height: 174cm, rate of respiration: 20/minute, temperature: 98.2F, Weight: 56kg and body mass index is 19kg/m2. During inspection it is observed that shape of chest of patient is barrel and patient respire with the help of accessory muscle which indicates presence of emphysema (Smeltzer et al, 2009). This less amount of air in the lungs causes disturbance in breathing pattern (Celli, 2007). This alteration in shape of chest shape occur due to the decrease in flexibility of lungs muscles and therefore extra energy is required for this forceful type of breathing as a result client is not able to eat in adequate manner and loosen the weight (Smeltzer et al, 2009). Percussion indicate presence of tympanic resonance that occur because of less motion of diaphragm and presence of wheezing sounds indicating COPD (Celli, 2007). Auscultation indicate that there is extended forced expiratory pattern due to the decrease in air in the lungs. Congestive heart failure or lung fibrosis is differentiated from COPD on the basis of wheezing sound and presence of ronchi. Club shape finger of patient may indicate the presence of other disease condition such as cancer of lungs, bronchiectasis, and pulmonary fibrosis. The skin mucosa of the client is bluish which signify that less of oxygen in blood (American thoracic society, 2004) . Physical assessment of respiratory system does not provide the relevant and valid information for the detection of disease condition but related co morbid state and differential diagnosis are well judged with the help of thorough examination (Mcivor et al, 2004). However the decrease in flow of air in lungs is not predicted with the help of history collection and general assessment. Therefore pulmonary functional test such as spirometry is useful in diagnosing COPD (Travers et al, 2007). Furthermore for identification and confirmation of the COPD and its progress level can be easily identify with the help of spirometry (Stoloff, 2011). COPD is well detected with the help of satandarized device that is spirometry however this device is inconsistent in clinical area (Gold, 2008). Spirometry reading of patient reveals that FEV1/FVC is 56% , this value is less than 70% and it is categorize as stage two that is moderate. However spirometry is not believed to be valid tool for the evaluati on of broad category of airflow obstruction diseases (Borg, 2010, American Thoracic Society, 2004, GOLD, 2008). But provision of bronchodilators are beneficial in diagnosis of asthma and COPD and determine the limit of flow of air that is not reversible fully. Still the exact value of reversibility that helps in judging the patient asthmatic or COPD pdiseases is not known. However differential diagnosis of COPD can be clinically evaluated and also can determine by various non invasive procedures (Vestbo, 2010). Chest radiography is useful technique in excluding various differential diagnosis such as pneumothorax, chronic heart disease, pneumonia (Man et al, 2004). Therefore, to clear out the differential diagnosis, a proper clinical examination and simple investigations including chest radiography could resolve uncertainty if any (Vestbo, 2010). Radiography of chest mostly exhibit clear interstitial markings in patient with chronic bronchitis however there is no particular outcomes that provide evidence that radiography is beneficial for the diagnosis of COPD or Chronic bronchitis (Kane Graham, 2004). In the patient, chest radiography reveals that lung field is hyper distensded, diaphragms are flattened and retrosternal space is more which is the sign of emphysema. Moreover determination of various changes in lungs in case of emphysema can be determined with the help of superior type of chest film (Vestbo, 2010). However with the help of chest x ray it is not possible to detect initial stages of COPD (Gold, 2008). Therefore high resolution Computed tomography is used for identifying emphysema in the initial stages. Moreover the lesions in the lungs can be identifying with the help of high resolution computed tomography (HRCT) without any trouble (Gold, 2008). There are various other diagnostic test which are helpful in COPD confirmation with more accuracy such as arterial blood gas analysis, cardio pulmonary exercise test (GOLD, 2008). The presence of pulmonary emphysema and various other alternative diseases such as asthma and other minor airway diseases can be determined by the value of total lung capacity and diffusing capacity for carbon monoxide(Vandevoorde, 2006) suggest that through examination of blood gas, saturation of oxygen in blood, blood perfusion is determined (Smeltzer et al, 2009). (also supported that arterial blood analysis in moderate and severe cases of COPD should be performed (Vestbo, 2010). However this test is not is not a reliable test to confirm COPD but in high risk cases of emphysema this test is helpful to know hypoxemia (Travers et al, 2010). Value of ABG analysis of patient was PH-7.30, Pao2-84mmHg, Paco2-48mmHg, HCO3-25mg/dl and Sao2 94% Haemoglobin level of patient was 13.4 mg/dl . Chronic Obstructive Pulmonary Disease is the disease of respiratory system that causes non reversible and progressive decrease in pulmonary function (Higginson, 2010). The air flow is not proper in lungs due to this reduction of lung function. The diseases it includes are bronchitis, asthma and emphysema. It effect more than three million people in England. (Jones, 2001) In the Western World, the main cause of COPD is smoking, smoking is related with over 90% of this disease, however COPD occurs in merely 10% to 20% of chronic chain smokers. (Beyer et al, 2008)Respiratory illness is also occurred by passive smoking. (Higginson, 2010) Genetic factor is also responsible for yhe occurrence of COPD however there is only one genetic factor alpha antitrypsin that involes in causing this disease. The lack of this genetic factor is the single major risk factor for the occurrence of this disease. Though determine in only one percemt cases of COPD. Contact with noxious substances is the most c ommon cause of COPD. (Yohannes and Hardy, 2003) There are various diseases in childhood such as pneumonia and whooping cough prior to the age of 12 year are considered to be the risk factor of bronchiectasis and bronchiolitis. Females are at high risk of COPD than man however argues that there is no difference in occurrence of COPD in male and females (Lindberg, 2006). The progress of the disease inside body is mostly described by the inflammation that involve central and peripheral airways. By the inhalation of the noxious substances or irritants , inflammation occurs in the central airway. Due to this soreness , there is more secretion of mucus that damage the ciliary clearance. As a result the glands of the mucus turn into large size and therefore more production of mucus take place due to more amount of goblet cells. This increase production of mucus provides an brilliant medium for the growth of microorganism cause the impairment of airway. Repeated infection causes damage to cilliary body and further inflammation. This progression leads to constriction of airway . Following obstruction trapping of air inside lungs occurs that result in hyperinflation, difficulty in breathing and less tolerance to exercise. The chronic obstruction diseases are chronic bronchitis, emphysema (Higginson, 2010). For the appropriate management of COPD, holistic approach must be taken in account (Paul, 2004). Individually management plan must be made that covers the essential components such as termination of smoking, dietary management and function of lungs should be maintained by medication therapy. Instant treatment in emergency unit is started with the provision of oxygen and sometime bronchodilator may be beneficial to find out reaction to the treatment (Gold, 2008). Moreover administration of oxygen helps in treating hypoxemia and hence improves breathing problem (Downs Appel, 2007). However excess utilization of oxygen may lead to withholding of carbon dioxide level in lungs. So it should be provided with cautious (Kevin, 2007). Patient was provided with oxygen therapy for short duration, the partial pressure of oxygen of the patient is 74% so there is no requirement of oxgen for long term (Gold, 2008). Drug therapy is beneficial for the treatment of COPD and it is provided according to the seriousness level of disease condition (Incalzi et al, 2006). In mild COPD cases, short acting beta 2 adrenoceptor agonists is advised whereas in moderate and severe cases long acting beta 2 adrenoreceptor agonist are recommended. Moreover anti cholinergic is beneficial and easily bearable in older people. Pharmacotherapy is essential in relieving the various symptoms however there is no medication that reveals long lasting improvement of lung function (Gold, 2004). Suggest that with the combination of different drug therapy can give better result and reduce the harmful effects as compared to large amount of single dosage. The preference of different bronchodilators depends upon, accomplishment of desired reaction and ill effects (Downs Appel, 2007). Suggest that due to very few harmful effects and less dosage requirement, inhalation route is chosen for treatment (American thoracic society, 2004) . The widely used short acting beta agonist are salbutamol, terbutaline, pirbut erol and salmeterol, formoterol are the long acting beta agonist also methylxanthines such as theophylline , antichollinergic and inhaled corticosteroid are commonly used that are beneficial in reducing m mucus secretion in airway (Nazir and Erbland, 2009). Pharmacotherapy in the patient was begin with the administration of combined therapy of salbutamol of dose 50Â µg with ipratropium 20Â µg. these are the bronchodilators which is provided with the help of inhaled and injection of theophyllin also administered through intra muscular route. There are some other drugs that are beneficial in severe stage such as antioxidants and immunoregulators (Gold, 2008) Improper nutrition in COPD patient is quite general and it has harmful influence on the pulmonary functioning. So helping the client in maintenance of adequate nutrition level is important and beneficial in improving the respiratory functioning (Shepherd, 2010). Moreover the client whose BMI is less than 21 kg/m2 should be given supplementary diet in order to improve condition of client further (Vermeeren et al, 2001). However age associated alteration in structure, height, muscular changes and if value of BMI is more than also malnutrition cannot be identified (Shepherd, 2010). In patient BMI is in normal category instead patient is advised to take adequate calories, carbhohydrate and proteins in diet. Patient is also advised to avoid caffeine, restrict sodium and taking more milk. The other preventive measure is vaccination of influenza. It has much influence in prevention of various acute respiratory illnesses along with COPD. This type of vaccination must be advised to each patient suffering from COPD (Wongsurakiat, 2004) . Patient who is moderate or severe deterioration of lung function then pulmonary rehabilitation is beneficial to gain maximum functioning to manage with disease condition. Patients are motivated to do different types of exercise to keep body healty Such as steps up, walking , various arm exercises, self handling of various activites such as taking medication, that helps in keeping the function of different system appropriately. Also exercise for decreasing hyperinflation and manage dyspnoea such as deep breathing and pursed lip is advised to the patient (Barnett, 2008). Moreover advantages of rehabilitation of lung fuction maintain for numerous months even after the end of this program (O` Donell, 2007) . COPD is the most prevalent problem that effect mostly elderly people. The mai symptom of COPD is shortness of breath, production of cough with sputum. The main cause of occurrence of this disease is cigarette smoking. History taking and physical examination is beneficial in excluding all the differential diagnosis. Through spirometry diagnosis of COPD can be made. Pharmacology is helpful in controlling the further spread of disease but medication does not provide efficient result in long term care. CASE STUDY ON SPINAL CORD INJURY This case study will throw light on the complete physical examination and diagnostic test and a range of laboratory investigation to confirm the diagnosis. It will then undergo detail treatment plan along with differential diagnosis to explain the appropriate intervention on the basis of present evidence sources. Also it will explore the recent issues regarding care of spinal cord injured patent. The actual name of the patient is changed in the study so that data cannot be recognized (Dimond, 2002). Mr. Malik Aggarwal is a 21 year old student studying in University of Greenwich doing mastering in marketing. During summer break in France, Malik was struck with an motorbike accident. During accident he fall harshly on the footpath from his bike and was lying towards his abdomen . This accident was witnessed by the policeman and he quickly gave call for first aid management. Ambulance was arrived soon and emergency staff identify the severity of Malik injury, they protect the neck of the victim with the help of strong board and immobilize the part before transferring him to the emergency department of the closest hospital. Patient was awake and also familiarized with current date, day and location. He was also replying in well manner. After reaching hospital, he complained of loss of feeling on his both legs, severe pain in neck, mild pain on his back and all extremities, patient was not able to move his neck and lower extremities properly. The assessment was carried out by the eme rgency specialist staff, and found that there were contusions and lesions present on his trunk and lower extremities, the restriction of the neck was rapidly maintained by the staff with the help of firm cervical collar. In order to limit further deterioration of condition, patient was supported with cervical traction and head was also supported with motion restricted devices that are helpful in maintaining proper alignment (Grubb, 2006) . The cardinal signs were checked and indicate that patient has Blood pressure of 100/70, pulse rate: 90/minute, respiration: 20/mt, temperature: 98.4 F and oxygen saturation was 90%. During history collection main emphasis should be given on complete mechanism that how the injury took place, this data is confirmed from the witness and also who is present at the time of accident to so as to proceed accurately towards confirmation of diagnosis (Schreiber, 2009). Other physical and social factors should be noticed that may interfere with the proper assessment of pain (Cruz-Almeida, 2007). Moreover complete history plays an important role in knowing possible etiology of different symptoms and also helps in excluding differential diagnosis. Proper pharmacological history , family history and dietary history should be taken because it might be beneficial in knowing the disease (Cox, 2008) . History collection of patient reveals that patient was anxious and had complaint of pain at the site of neck. The constant pain occur due to the contraction of muscles of neck muscls. There were presence of mild lesions on the trunk and extremities. Therefore it might be the case of injury on cervical cord because continual pain is the indication of spinal cord injury (Lee and Ostrander, 2003) . The exact cause of injury is the extreme flexion of head towards the chest that is due to hyperflexion. Moreover if the main reason of spinal cord injury is hyperflexion or hyperextension then it might be the case of spinal cord injury (ElFaramawy, 2009). Client gave appropriate reaction to each question during history taking , this shows that patient has good level of consciousness. As patient vital sign indicate that patient has hypotension, low respiratory rate and decrease in temperature. The one reason for the occurrence of hypotension might be the interference of vagal and symphathetic vascular tone (Karlet 2001). The client symptoms of hypotension, bradycardia indicates that it might be due to neurogenic shock (McLeod, 2004). After the collection of data it is essential to carry out physical assessment by covering all the aspects. Adequate Physical assessment is the basis in determining the injury related to spinal cord (Bono and Lee, 2004). Moreover physical examination especially of neurological system is beneficial in gathering the baseline data. The main section in neurological examination include will be cranial nerves, sensory and motor function and also reflexes (Noah, 2004). Assessment take place by mkaintaing proper interpersonal relationship with patient. While doing inspection assess for the mental condition, intellectual and cognitive response of the patient (Crimlisk, Grande 2004). Assess for the posture of the patient, if posture maintained by patient is decerebrate thenit may indicate trauma in the midbrain. With the help of Glasgow coma scale, level of consciousness should be assessed and also this scale is beneficial in determining the sensory, motor and verbal response. However the response through this scale is not satisfactory in determing the verbal function (Iyer, 2009). Assess for the extremities for spasticity, presence of weakness, flaccidity as these are the significant mark of damage to neurologic system and also assess for the pronator drift which signify hemiparesis (Crimlisk and Grande, 2004). In the patient, level of consciousness through Glasgow coma is assessed and it is found to be 13 which is normal(Iyer, 2009). Inspection of the patient indicates that there is presence of abrasions on the body and he has difficulty in breathing which is indicated from the use of accessory muscles. This data may be crucial in determine that damage occur in between C3 and C5 vertebrae (Walker, 2009). Neck and trunk should be properly palpated as it is helpful in determine any kind of defect in the neurological system. Palpation should be done in an appropriate manner starting from the cranium and regularly descending along the vertebral disc. On palpation of patient there is feeling of rigidity of muscles of cervical and tenderness. So there are chances of cervical injury (Noah, 2004). Diagnosis of spinal cord injury is based not just on history collection and examination infact complete neurological examination and radiographic studies are essential for the confirmation of diagnosis (Berney, et al 2011) . Spinal nerve assessment should be done with the help of hammer that should be strike beneath the knee. Striking causing sending of nerve impulse and thigh muscles contracted due to this flow of nerve impulse. If there is no contraction of muscles then it indicates there is distruption in the pathway and some sensory or motor deficit. In patient there was mild contraction of muscle fibre indicate neurological deficit(Cox, 2008). After that cranial nerves should be assessed by various method such as recognization of smell, assessment of the vision through snellen chart, assess for speech ,facial expression, assess for optic fundi with the help of opthalmoscope, if there is presence of papilloedema it may be the case of increase intracranial pressure. In patient all the cranial nerves are intact and also no papilloedema is present which exclude the diagnosis of increased intracranial pressure (Cox, 2008) . Patient motor and sensory function is determined by the American Spinal Injury Association (AISA) impairment scale. In this scale sensory deficit and motor impairment is recognized with the help of broad categorization. In the patient the strength of elbows, wrist was normal, the stretch of the biceps and triceps was also normal. The response of the patient towards light touch and pin prick was normal up to the inguinal area however due to weakness of lower limbs, the response of lower extremities was not adequate indicate sensory deficit due to spinal cord trauma (Dodwell, 2010) . However the proper alignment of the vertebrae and recognizing of fracture cannot be possible with such scale so for that radiography is essential (Sheerin, 2005). The radiography is beneficial in determine the fracture of thoracic vertebrae, it gives reliable information but it is not useful in case of cervical vertebrae as these vertebrae are to small to be visible appropriately in radiography (Jorge, 2009). Radiography of the patient provide inadequate data as the film was not properly clear. The deep examination of displacement of bone segments and fractures is possible with the help of computed tomography. The CT scan is beneficial in visualization of the image in different cross section (Jorge, 2009). It is possible to get exact information regarding injury of bone with the help of CT scan and radiography films however the injury to the soft tissue on the cord, intervertebral disc then these diagnostic test does not provide complete information regarding soft tissues (Sheerin, 2005). The CT scan of patient exhibit that injury take place at the level of C5 spine. Magnetic Resonance Imaging is helpful in visualization of injury that occurs on soft tissues by providing well clarify image. The further deterioration and injury that occur due to soft tissues is clearly recognized with the help of MRI (Sheerin, 2005). The MRI of patient shows that there is no soft tissue injury. Functional studies such as positron emission tomography, electromyograms are not of use in case of conscious client. They are only essential in patients who are not cooperative (McDonald and Sadowsky, 2002). From the above history collection, physical assessment, various diagnostic test it is clear that client has cervical injury at the level of 5 intercostals vertebra. Spinal cord is the basic part of central nervous system. It consists of thirty one segments. However due to the fusion of coccygeal bones there are 30 segments in vertebral column (Sheerin, 2004). Spinal cord has two region that is cervical and lumber and it is consist of grey matter (Sheerin, 2004). Approximation of 500 to 700 people each year suffers from traumatic spinal cord injury in UK. The main aetiology of spinal cord injury is straight mechanical injury and injury develops due to the compression on cord (Pellatt, 2010). This compression develops from traumatic and non traumatic reason (McDonald Sandusky, 2002). Due to this overstress of cord, intense flexion, extension or rotation develops. If injury develops due to direct force then within little duration discharge of enzymes from cells and vasoactive substance take place. After that neutrophills and macrophages infilterate in that region. The amount of potassium in extracellular fluid boost up and cells become depolarized and result in hypoxic conditions. Where as in case of indirect cause, vascular system compromised causing lack of blood supply in tissues. Which further leads to development of various haemorrhages, due to this haemorrhages the endothelium of blood vessels become disrupted. Further development of aneurysms occurs causing thrombi development in blood vessels. Due to stimulation of vagus nerve, imbalance thermoregulation develops and because of dermal blood vessel dilatation various life threatening sign and symptoms are developed such as neurogenic shock due to vasodilatation (McDonald and Sadowsky, 2002). There are also development of various syndrome such as anterior cord syndrome which occurs due to the injury to the two third of spinal cord in the anterior side, and next is the posterior cord syndrome that occurs due to the injury to the two third of spinal cord in the posterior side (Bailes et al, 200) . Central cord syndrome mainly occupies the cervical part of spinal cord. This syndrome usually influence elderly people and develop cervical spondylosis due to hyperextension. This spondylosis and hyperextension injury together put compression on the anterior and posterior side of cord. Due to which ligament turn towards inner side and put force on the anterior horn cells. This will further causes development of oedema (Bailes et al, 200) . Management of the patient begins from the site of the accident. First priority of the management is the maintenance of the airway, breathing and circulation. Oxygen therapy helps to prevent hypoxic conditions along with that oxygen therapy stop secondary injury that occurs due to the hypoxic conditions. For maintain airway jaw thrust method should be used chin lift method should be avoided as this may deteriorate the neck by extension (Pellatt, 2010). Immediately stabilization of spine must be maintain with the help of stiff cervical colour. The client must be positioned on hard board so as to maintain proper alignment. If there is requirement of intubation then it should be maintained with the help of three people without mobilizing the patient. However immobilization is not as important as the oxygen therapy because death of the patient may take place due to development of encephalopathy in hypoxic condition (Sheerin, 2005). After the confirmation of diagnosis, drug therapy should be started without any delay. Currently this drug therapy is recognized as basic treatment and helps in limiting secondary damage due to hypoxic condition. Steroid treatment must be started immediately. Methylprednisolone is more preferable. The amount needed for this drug is 30mg/kg in 15minutes, subsequently 5.44mg/kg/hr within 24 hours. Steroid treatment helps in improving neurologic deficit through blood flow toward central nervous system. However this drug is helps in only protection of neurological function and also use of elevated amount this drug result in side effects such as gastric bleeding and infection of wound (Weant, 2008). Further supporting, this drug is usually beneficial within 8 hours of injury. Also in the study organized by the researcher in random controlled trial to see the impact of nimodipine and methylprednisolone on patient with spinal cord injury in acute phase is that both the drugs produce side e ffects and these drugs are not of much beneficial (Pointillart, 2000). Also respiratory and cardiovascular function should be adequately maintained in spinal cord injury. Excessive damage if occur by spinal cord injury has remarkable effect on respiratory system. Mostly colloidal solutions maintain pulmonary wedge pressure. (Nockels, 2001) Moreover due to spinal cord injury the tidal volume generated by accessory muscles is not adequate and result in further damage to pulmonary function so there is need of maintainence of respiratory function. Also hypotension may develop in patient as a result of neurogenic shock. Therefore it is essential to check blood pressure and average arterial pressure should be more than 85mmHg. However if blood pressure is too low than it can be managed with the help of vasopressin agent such as dopamine (Sheerin, 2005). Mr. Malik was provided oxygen about 2 litres/min so as to maintain proper perfusion. Pulse oxymetry was continued and part

Art of the Romantic Period

During the Romantic period, composers had shown their romantic side. The expressive part in all artists was being shown. The passion in art, the variety of bold colors, the freedom of expression, and how one feels through the sound of a piano or violin, it was all being shown. Much of what the classical period was still remained during the romantic period, but to most, the romantic period was so much more. The music was more emotional and expressive, and had even influenced artists that weren’t musicians to be romantic as well. All artists were becoming the romantics of the time, and what a time it was for the arts. The romantic period will always be remembered as a time in history when passion was important, expression was used, and emotion was seen and heard. There are many characteristics involved in the romantic period. The individuality of style was an important characteristic. Each composer had his own style that showed his innermost feelings through and expressed emotional piece of work. Expressive aims and subjects were also important during this period. The romantics explored a universe of feelings that included intimacy and flamboyance, melancholy and unpredictability, longing and rapture Romanticism (1820-1900) in music was brought to the world during the early nineteenth century. This music stressed emotion, imagination, and individualism. The Romantic period was about freedom of expression and breaking away from time-honored conventions. This period in time had influenced many, or even all of the arts. Painters used bolder and more brilliant colors in their works. Also, they had preferred dynamic motion to gracefully balanced poses. Poetry was also changed during the romantic period. Emotional subjectivity was a basic quality in every type of art during this time. Many artists had become â€Å"romantics† and had become drawn to the realm of fantasy: the unconscious, the irrational, and the world of dreams. Romantics were fascinated with the middle age, the time of chivalry and romance. What neoclassicists had thought of to be the â€Å"dark ages†, the romantics had cherished. The spirit of revolution was â€Å"a dedication to the principles of equality, reason, and a representative government. † (Bishop 323) With the overthrow of Kings in America and France it did not stop the injustices or establish a utopia of reason. With the middle class growing a society developed and a new sensibility arose called romanticism, which glorified the individual and prized feelings over reason and intellect. â€Å"This period of revolutionary change and romantic reaction (1775-1850) laid down the principles, and discovered the demons of the first modern society. † (Bishop 323) Elements of romantic art and literature came about to respond to different social and historical circumstances. Poets of this time argued against the social injustices of early society. A woman named Mary Wollstonecraft wanted equal rights for woman, and a Spanish painter Goya bitterly depicted the cruelty of war. Authors in England and North America such as Wordsworth and Emerson saw nature as a mirror of the human imagination. Painters developed now techniques of color and light to render the natural landscape’s sublime beauty. Other people sought escape in the past, and had a taste for picturesque medieval architecture. As the industrial life became dull and mechanical, the lure of exotic lands spurred the imaginations of architects such as Nash and painters such as Delacroix and Ingres. The people of the romantic age were fascinated with evil, the demonic, and the grotesque and the dark side of things that were reflected in the novel, with its medieval setting and tortured characters. The most famous Gothic novel was Mary Shelley’s â€Å"Frankenstein†, which was a summation of the romantic motifs: â€Å"the genius, the noble savage, the protest against injustice, and the fascination with evil. † At one point in the study of the Romantic period of music, we come upon the first of several apparently opposing conditions that plague all attempts to grasp the meaning of Romantic as applied to the music of the 19th century. This opposition involved the relation between music and words. If instrumental music is the perfect Romantic art, why is it acknowledged that the great masters of the symphony, the highest form of instrumental music, were not Romantic composers, but were the Classical composers, Haydn, Mozart, and Beethoven? Moreover, one of the most characteristic 19th century genres was the Lied, a vocal piece in which Shubert, Schumann, Brahams, and Wolf attained a new union between music and poetry. Furthermore, a large number of leading composers in the 19th century were extremely interested and articulate in literary expression, and leading Romantic novelists and poets wrote about music with deep love and insight. The conflict between the ideal of pure instrumental music (absolute music) as the ultimate Romantic mode of expression, and the strong literary orientation of the 19th century, was resolved in the conception of program music. Program music, as Liszt and others in the 19th century used the term, is music associated with poetic, descriptive, and even narrative subject matter. This is done not by means of musical figures imitating natural sounds and movements, but by imaginative suggestion. Program music aimed to absorb and transmit the imagined subject matter in such a way that the resulting work, although â€Å"programmed†, does not sound forced, and transcends the subject matter it seeks to represent. Instrumental music thus became a vehicle for the utterance of thoughts which, although first hinted in words, may ultimately be beyond the power of words to fully express. Practically every composer of the era was, to some degree, writing program music, weather or not this was publicly acknowledged. One reason it was so easy for listeners to connect a scene or a story or a poem with a piece of Romantic music is that often the composer himself, perhaps unconsciously, was working from some such ideas. Writers on music projected their own conceptions of the expressive functions of music into the past, and read Romantic programs into the instrumental works not only of Beethoven, but also the likes of Mozart, Haydn, and Bach! The diffused scenic effects in the music of such composers as Mendelssohn and Schumann seem pale when compared to the feverish, and detailed drama that constitutes the story of Berlioz's Symphonie fantastique (1830). Because his imagination always seemed to run in parallel literary and musical channels, Berlioz once subtitled his work â€Å"Episode in the life of an artist†, and provided a program for it which was in effect a piece of Romantic autobiography. In later years, he conceded that if necessary, when the symphony was performed by itself in concert, the program would need not be given out for the music would â€Å"of itself, and irrespective of any dramatic aim, offer an interest in the musical sense alone. † The principle formal departure in the symphony is the recurrence of the opening theme of the first Allegro, the idee fixe. This, according to the program, is the obsessive image of the hero's beloved, that recurs in the other movements. To mention another example: in the coda of the Adagio there is a passage for solo English horn and four Tympani intended to suggest â€Å"distant thunder†. The foremost composer of program music after Beriloz was Franz Liszt, twelve of whose symphonic poems were written between 1848 and 1858. The name symphonic poem is significant: these pieces are symphonic, but Liszt did not call them symphonies, presumably because or their short length, and the fact that they are not divided up into movements. Instead, each is a continuos form with various sections, more or less varied in tempo and character, and a few themes that are varied, developed, or repeated within the design of the work. Les Preludes, the only one that is still played much today, is well designed, melodious, and efficiently scored. However, its idiom causes it to be rhetorical in a sense. It forces today's listeners to here lavishly excessive emotion on ideas that do not seem sufficiently important for such a display of feeling.

Drug Use And Attention Deficit Hyperactivity Disorder (...

Ritalin is a prescription drug used primarily in the treatment of behavioural problems in children such as Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD) (National Drug Intelligence Centre 2006). It is estimated that 11 percent of Australians between the ages of 6 to 17 are affected by ADD or ADHD and the amount of Ritalin being prescribed has doubled in the last 10 years ( Schriever 2012). The brand name for Ritalin is methylphenidate, a drug that stimulates the central nervous system. Its primary use is to stimulate the brain and improve concentration, therefore helping the child control impulsive behaviour and overactivity (Royal Children’s Hospital Melbourne 2010). When a child is taken to see a doctor for behavioural problems the General Practitioner will refer these children to a child phycologist or paediatrician. They are then examined and asked a series of questions which inevitably leads to being diagnosed with ADD or ADHD and leaving with a prescription for Ritalin (G Bell 2014). This medication has been known to cause adverse side effects in many children. There is also the problem of misdiagnosing the child’s condition and with the view that alternative treatments are available, Ritalin should not be used as a first solution in the treatment of behavioural problems in children. Ritalin should not be used as a first option due to the ongoing side effects that some children suffer from taking this medication. There areShow MoreRelatedAttention Deficit Hyperactivity Disorder ( Adhd )1552 Words   |  7 PagesATTENTION DEFICIT HYPERACTIVITY DISORDER Seth was a second grader at West Elementary. He constantly got reprimanded by his teachers for not paying attention in class. He could not understand the information given to him during the school day. He thought he was stupid and useless. But he was not. His parents got him tested by a doctor for ADHD. He is one of many kids in the United States who have been recognized as having it. Attention Deficit Hyperactivity Disorder is a major issue in the educationRead MoreEssay On ADHD1259 Words   |  6 Pages Many may ask what the causes of attention-deficit/hyperactive disorders are but the cause of ADHD is not completely understood yet. People suggest that there may be biological abnormalities, hereditary factors, and environmental factors for those who suffer from ADHD. Individuals with attention-deficit/hyperactive disorders may have biological abnormalities such as brain structure abnormalities or abnormal biochemical levels (Comer, 2016). Brain structural abnormalities tend to occur in theRead MoreAttention Deficit Hyperactivity Disorder (ADHD), Ritalin, and the Brain1606 Words   |  7 PagesAttention-Deficit Hyperactivity Disorder, Ritalin, and the Brain Attention-Deficit Hyperactivity Disorder, more commonly referred to as simply ADHD, is the most commonly diagnosed disorder among American children today. According to the National Institute on Mental Health an estimated 3 to 5 percent of school age children are affected by this disorder. (1) There are more diagnosed cases of ADHD of in the United States than there are anywhere in the world. The main symptoms of ADHD include developmentallyRead MoreIs Adhd over-Diagnosed Among School Children1409 Words   |  6 PagesIs ADHD Over-diagnosed Among School Children? After reading the review, (Is ADHD over-diagnosed among school children?) by C. Collins, I am in agreement with T. E. Elder in that yes, ADHD is over-diagnosed. I chose to accompany the review by C. Collins with the article, Attention Deficit/Hyperactivity Disorder, which originated from the Facts on File; Issues and Controversies Database. After reading both the review and the article I highly believe that ADHD is definitely over-diagnosed. In theRead MoreAttention Deficit Hyperactivity Disorder ( Adhd )1100 Words   |  5 PagesAttention deficit hyperactivity disorder (ADHD) What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a psychiatric illness characterized by problems with attention as well as hyperactivity. Individuals also tend to act impulsively. The exact cause is unclear but is likely related to genetic factors as first-degree relatives are often affected. The disease frequently begins in childhood and may progress into adulthood. 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The prevalence and attention given to ADD/ADHD as a disorder has not become apparent until more modern times. With the coming of Drugs, treatment seemed to become common and successful. There are many risk factors believed to contribute to developing ADD/ADHD. However, no correlates are indeed

The Death Of Romeo And Juliet s Death - 1312 Words

Once upon a time there was a boy named Romeo and a girl named Juliet, who lived separately but loved each other dearly. This story is about a boy and a girl whom their families hated each other deeply and they were enemies because they always fight with each other. The end of this beautiful love ended in tragedy with the death of the two star- crossed lovers, Romeo and Juliet. Many people had different opinions about who to blame for Romeo and Juliet’s death. Some of them said that the environmental factors (fate) caused their deaths. Others said that the authority Figures was blamed for their deaths. Part of people were blaming Romeo and Juliet (themselves) for their death. Actually, all of these statements blame for Romeo and Juliet’s death and there are a lot of evidences that would support my opinion. One of the causes that lead to Romeo and Juliet’s death is the environmental factors (fate included). Environmental factors have been about the time that they were living in, the feud between the families, and destiny. The feud of the families caused their death because if the families weren’t enemies, then, they won’t get married secretly, or god had chosen for them this life. â€Å" I hear some noise.—Lady, come from that nest, of death, contagion, and unnatural sleep. A greater power than we can contradict, Hath thwarted our intents.† (5.3.156-159). This quotation means that when Juliet woke up and finds that Romeo is dead, Friar Lawrence tells Juliet that a higher powerShow MoreRelatedRomeo And Juliet s Death1927 Words   |  8 PagesIn the story of Romeo and Juliet, the two lovers remain separated because of one man’s decisions that change the whole story. A decision no matter its size, or how thoughtfully it is made, can lead to an out come that may be small and even life changing. One has to be blamed for an ending, so who is at fault for Romeo and Juliet’s death? Although, some might argue Friar Lawrence remains at fault for Romeo and Juliet’s death, Romeo is actually at fault for their deaths since, Romeo kills Tybalt, whichRead MoreThe Death Of William Shakespeare s Romeo And Juliet1660 Words   |  7 Pageslook romantic when portrayed as the conclusion to a love story, like in Romeo and Juliet, a masterpiece by the beloved William Shakespeare. Death itself is dramatic, but there is something more to beyond the gruesome or romantic aspects of death, particularly when it comes to suicide. The Death of Socrates manages to grip the viewer with its dramatic climax to death, yet saying something more with it s imagery. The Death of Socrates effortlessly channels utter despair, and yet, unwavering defianceRead MoreWho to Blame in Romeo and Juliet ´s Death? Essay698 Words   |  3 Pagesresponsible for the two lovely lover-Romeo and Juliet’s death? In my opinion, there is no one particular person to really blame on their death. However, it is every single person are should be blamed for the deaths of both Romeo and Juliet. If I was answering the question of who were the few most responsible people for their tragedy-it would be three people. Because of people’s decision and different point of view, the people most responsible for the deaths of Romeo and Juliet are Lady Capulet, Nurse, andRead MoreWilliam Shakespeare s Romeo And Juliet767 Words   |  4 PagesDrew the Dagger; Romeo, Juliet and Others Accountable for Their End Everyone in the world has experienced love on at least some level. Romeo and Juliet from William Shakespeare s famous play Romeo and Juliet were so deeply in love they took their own lives in order to avoid separation. Yet, who is to blame for the early deaths of Romeo and Juliet? Is it their ancestors fault? Their parent s? Or are Romeo and Juliet the only ones to blame? The characters of Romeo and Juliet are Paris, CapuletRead MoreWilliam Shakespeare s Romeo And Juliet759 Words   |  4 Pagesthe Sword; Romeo, Juliet and Others Accountable for Their End Everyone in the world has had love on at least some level. Romeo and Juliet from William Shakespeare s famous play â€Å"Romeo and Juliet† were so deeply in love they killed themselves to stay together. But who is to blame for the early death of Romeo and Juliet? Is it their ancestors fault? Their parents? Or are Romeo and Juliet the only ones to blame? The characters of Romeo and Juliet are Paris, Capulet, Lady Capulet, Juliet, The NurseRead MoreThe Tragedy Of Romeo And Juliet By William Shakespeare976 Words   |  4 PagesThe tragedy of Romeo and Juliet, which represents love and sacrifice, is one of the most famous plays ever written by Shakespeare. The play was written in 1595 and published in 1597. Romeo and Juliet is a sad love story with feuding families, the Capulets and the Montagues. The play takes place in Verona, Italy. It contains the heart-breaking story of the stars-crossed lovers as they fall in love instantly. Friar Lawrence is the priest who married the co uple. He marries them in hopes that the twoRead More Theme of Fate and Choice in Shakespeares Romeo and Juliet Essay782 Words   |  4 PagesWilliam Shakespeares Romeo and Juliet In William Shakespeares tragic play Romeo and Juliet, there are four quotes about fate and choice. The characters in the play choose their own fate, it happens because of their choices or actions. First, in the beginning of the play Romeo and Juliet are referred to as a pair of star-crossed lovers (Romeo and Juliet, Prologue). Second, Romeo explains to Mercutio how he has a dream that if he goes to the Montague party he will die, but Romeo chooses to go toRead MoreWilliam Shakespeare s Romeo And Juliet985 Words   |  4 PagesOne of the best plays, Romeo and Juliet, takes place in Verona, Italy. This play is a tragicomedy that involves many puns, jokes and laughs. Every character makes mistakes that contributes to the tragic deaths of Romeo and Juliet, yet, throughout the play, there is one character prompting the feud, Mercutio. Mercutio is the character most responsible for the deaths of Romeo and Juliet because he causes problems for both families even after his death. Mercutio pushes Romeo to crash the Capulet’sRead MoreWilliam Shakespeare s Romeo And Juliet1616 Words   |  7 Pageslove can also cause some of life s most controversial battles. These battles could stem from lack of patience, disagreement of moral values, and in some cases, an absence of attraction overall. In Romeo and Juliet by William Shakespeare, the issues that drive Romeo Montague and Juliet Capulet s to each of their dreadful misfortunes are inevitable. When it comes to many of Shakespeare s plays, Aristotle s theory is used to describe them as tragedies. Romeo and Juliet is known by many as a tragedyRead MoreWilliam Shakespeare s Romeo And Juliet1492 Words   |  6 PagesDeshal Desai Professor: Thomas Gilligan EN 358 29 July 2016 Romeo and Juliet The play Romeo and Juliet, by William Shakespeare, is known for its romantic tragedy between two star-crossed lovers and whose families are each other s enemies. The outcome of their own family’s enemy brings the death of the lovers. With all of the deaths, who is truly to blame for Romeo and Juliet s deaths? Friar Lawrence is most to blame for many obvious, yet overlooked reasons. If we look at some unusual situations