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 ↑

The Fault in Our Stars

Our lives are a set of building blocks, and we always yearn to be perceived as skyscrapers. But not everyone has this capability. People have faults, and sadly, it can get to the point where those wrecking balls intervene. And the thing that was once a set of building blocks is no more. Some people have it harder than others. People live with cancer, deadly diseases that could ruin their lives. The Fault in Our Stars is a story mainly about the life of a girl named Hazel who falls in love with a person named Augustus.The problem is, that her and two other main characters in the story, Augustus and Isaac, have to live their lives battling cancer, which literally controls their â€Å"ordinary† lives. It is about the struggle (faults) that comes with dealing with cancer, and how they try to overcome these obstacles. Sometimes they succeed, and sometimes they do not. John Green titled his novel The Fault In Our Stars because the stars are the building blocks (a persons life), and the fault in those stars is what is keeping those building blocks from becoming skyscrapers, the wreaking ball (cancer).There are many significant themes throughout the novel that correlate to the title. The struggles in life with cancer, how love triumphs through hardship, and coping with the death of a loved one. These themes not only relate to the title but they also exemplify what this story is really about. Sets of building blocks that are slowly broken down, to the point where they are destroyed completely buy the wrecking ball, both literally and mentally. Cancer is something that it very hard to live with, and it generates numerous setbacks in life.The three main characters in this story, Hazel, Augustus, and Isaac live their lives battling cancer. They meet different obstacles every day, and the struggle is dealing with those obstacles. Hazel struggles with lung cancer, and every day she walks around with oxygen tank to help her lungs function. One time her cancer took a da ngerous toll when she woke up in the middle of the night at about four in the morning with an apocalyptic pain in the center of her brain. She woke her parents and was taken to the ICU. Hazel was knocked out, and they did save her.When she woke up in the morning her parents explained everything that had happened to her. â€Å"Mom and Dad told me that I did not have a brain tumor, but that my headache was caused by poor oxygenation, which was caused by my lungs swimming in fluid, a liter and a half(!!!! ) of which had been successfully drained from my chest, which was why I might feel a slight discomfort in my side, where there was, hey look at that, a tube that went from my chest into a plastic bladder half full of liquid that for all the world resembled my Dad’s favorite amber ale.My mom told me that I was going home, that I really was, and that I would have to get this drained every now and again and get back on the BiPAP, this nighttime machine that forces air in and out of my lungs. †(107) Hazel’s overexertion was very hard on her and the rest of her family. Now she has to get her lungs drained every once in a while and she is also on BiPAP. In my opinion this was more than just a struggle, this was a nightmare. A nightmare pioneered straight from her cancer, and it is just horrible. Augustus had lived a very rigid life with cancer.At the time that he met Hazel, he was cancer free with an amputated leg. When Augustus and Hazel went to the airport to go on their trip to Amsterdam, Augustus took very long to get to the plane when he said that he was going to go get food and come back. He told Hazel and her mom that the line at McDonald’s was really long but the truth came out when he was sitting on the plane next to Hazel. â€Å"Listen, sorry I avoided the gate area. The McDonald’s line wasn’t really that long; I just†¦. I just didn’t want to sit there with all those people looking at us or whatever.â₠¬  (145, 146)Here Augustus’s struggle with cancer is the looks that people would give him, looks that were just too hard to fathom. He didn’t want to get those looks. It bothered him. Augustus did not like people looking at him like there was something wrong with him. It was just mortifying. Isaac was Augustus’s friend that introduced him to Hazel. Isaac and Hazel went to support group together. Isaac suffered from eye cancer, and he was going to get a surgery that would eradicate himself of his cancer. The problem was that this surgery would steal his sight.This was a huge obstacle that cancer has set for him and he has to cope with the struggle of loosing his sight. But something even worse happened to Isaac when he told his girlfriend about the news (that he was going to be blind). His girlfriend stopped seeing him and it broke Isaacs heart. She was his true love and they said they would always be together, but she could not take it anymore. â€Å"She said she can’t handle it. I’m about to lose my eyesight and she can’t handle it. † (60) The reason his sight was going to be disdained was to loose his cancer.Meaning that the cancer was the cause of him loosing his sight, initiating the lose of his true love. This was Isaac’s huge struggle in life with cancer. Loosing the love of his life. The theme of struggles in life with cancer relates to the title because these struggles from cancer are the faults (struggles) that are in the stars, what is keeping the building blocks from becoming skyscrapers, which is initiated by the wrecking ball (cancer). Cancer is a deadly disease that constructs many problems in life.According to the love that was shared between Hazel and Augustus, no problem or â€Å"fault† would ever desist the love that these two had for each other. Augustus showed hazel that there is more to life than staying home and letting cancer consume you. It did not take long for them to fal l in love. Together they were unbeatable and they would never let anything bring them down. They both went through rigorous paths, but together, their loved steered themselves out of that hardship, and to safety. When Hazel was taken to the hospital because of her overexertion the nurse informed her about Augustus.â€Å"You’re not going to ask about your boyfriend? † she asked. â€Å"Don’t have one,† I told her. â€Å"Well there’s a kid who has hardly left the waiting room since you got here,† she said. â€Å"He hasn’t seen me like this, has he? † â€Å"No Family only. †(108) Even though it was very hard to see Hazel in that faze of discomfort, Augustus went because he loved her. He did not let hardship terminate his love for hazel. He would not let anything stop him from seeing her. When Augustus Osteosarcoma returned, he went to buy a pack of cigarettes in the middle of the night, and something went wrong with his G-tu be. He told Hazel to come and help him fix it.She took off her BiPAP, attached herself to an oxygen tank and went to help him before it was too late. When she saw him Augustus was in the drivers seat of his car covered in his own vomit. â€Å"Oh, G-d, Augustus, we have to get you to a hospital. † I gagged from the smell but bent forward to inspect the place above his belly button where they’d surgically installed the tube. The skin of his abdomen was warm and bright red. â€Å"Gus, I love you. † (244-245). Hazel loved Augustus so much that she took off her BiPAP, and left by herself with her oxygen tank to help Augustus in his urgent time of need.She did not let this â€Å"fault† bring down her spirits and she did what ever she could to keep him alive. She saved his life and if she did not go there to help him (and call 911) Augustus would not have made it. Their love triumphs through hardship, that is how powerful their love is. This theme relates to the title because the love is what keeps those stars or building blocks (peoples lives) up and running and they wont let the fault (hardship) get in the way of the love. Love isn’t something that can be wished upon, you have to have that click.The click between Hazel and Augustus was so strong that they would not let anything get into the way. At the end of the book Hazel is forced to cope with the death of her one and only soul mate, Augustus. Hazel was devastated. She loved him so much. At his funeral, she went up to Augustus’s coffin to say her last good bye. â€Å"I love you present tense,† I whispered, and then put my hand on the middle of his chest and said, â€Å"It’s okay, Gus. It’s okay. It is. It’s okay, you hear me? † I had-and have-absolutely no confidence that he could here me. I leaned forward and kissed him on the cheek. â€Å"Okay,† I said. â€Å"Okay.† (270)Hazel has been trying very hard not to let it get to her (the pain), and she does not want Augustus to be mad that he died on her. That is why Hazel says its okay, to apprise Augustus and make herself know that she can live through this. The theme of coping with the death of a loved one relates to the title of this novel because coping with the death of a loved one is another fault (struggle) that was in the stars that was initiated from death by cancer. Osteosarcoma was the wreaking ball that destroyed Augustus’s building blocks and Augustus’s passing was the wreaking ball that injured Hazel’s building blocks.There are many obstacles in life, and we always try to overcome them. Some people have it harder than others. Some people are forced to live their lives battling cancer. That is what The Fault in Our Stars is all about, the burden of living life as a different person with new problems everyday. Some days will be better than others, and some days will be worse. It’s a never-ending roller coaster. Su re there will be times where it slows down and rides along a straight path but there will always be those times where it goes fast and gets bumpy. People live today overcoming these endeavors.There are many themes in the novel that correspond with the title. The struggles in life with cancer, how love triumphs through hardship, and coping with the death of a loved one. These themes not only correlate to the title but they also portray the main idea of the story. Our lives are a set of building blocks and if we don’t learn how to eventually take and overcome the blows from the wrecking ball, we will never have that chance that all of us have always longed for (even for people who are not battling cancer), to not only become a skyscraper but to be commended as one. The Fault in Our Stars Our lives are a set of building blocks, and we always yearn to be perceived as skyscrapers. But not everyone has this capability. People have faults, and sadly, it can get to the point where those wrecking balls intervene. And the thing that was once a set of building blocks is no more. Some people have it harder than others. People live with cancer, deadly diseases that could ruin their lives. The Fault in Our Stars is a story mainly about the life of a girl named Hazel who falls in love with a person named Augustus.The problem is, that her and two other main characters in the story, Augustus and Isaac, have to live their lives battling cancer, which literally controls their â€Å"ordinary† lives. It is about the struggle (faults) that comes with dealing with cancer, and how they try to overcome these obstacles. Sometimes they succeed, and sometimes they do not. John Green titled his novel The Fault In Our Stars because the stars are the building blocks (a persons life), and the fault in those stars is what is keeping those building blocks from becoming skyscrapers, the wreaking ball (cancer).There are many significant themes throughout the novel that correlate to the title. The struggles in life with cancer, how love triumphs through hardship, and coping with the death of a loved one. These themes not only relate to the title but they also exemplify what this story is really about. Sets of building blocks that are slowly broken down, to the point where they are destroyed completely buy the wrecking ball, both literally and mentally. Cancer is something that it very hard to live with, and it generates numerous setbacks in life.The three main characters in this story, Hazel, Augustus, and Isaac live their lives battling cancer. They meet different obstacles every day, and the struggle is dealing with those obstacles. Hazel struggles with lung cancer, and every day she walks around with oxygen tank to help her lungs function. One time her cancer took a da ngerous toll when she woke up in the middle of the night at about four in the morning with an apocalyptic pain in the center of her brain. She woke her parents and was taken to the ICU. Hazel was knocked out, and they did save her.When she woke up in the morning her parents explained everything that had happened to her. â€Å"Mom and Dad told me that I did not have a brain tumor, but that my headache was caused by poor oxygenation, which was caused by my lungs swimming in fluid, a liter and a half(!!!! ) of which had been successfully drained from my chest, which was why I might feel a slight discomfort in my side, where there was, hey look at that, a tube that went from my chest into a plastic bladder half full of liquid that for all the world resembled my Dad’s favorite amber ale.My mom told me that I was going home, that I really was, and that I would have to get this drained every now and again and get back on the BiPAP, this nighttime machine that forces air in and out of my lungs. †(107) Hazel’s overexertion was very hard on her and the rest of her family. Now she has to get her lungs drained every once in a while and she is also on BiPAP. In my opinion this was more than just a struggle, this was a nightmare. A nightmare pioneered straight from her cancer, and it is just horrible. Augustus had lived a very rigid life with cancer.At the time that he met Hazel, he was cancer free with an amputated leg. When Augustus and Hazel went to the airport to go on their trip to Amsterdam, Augustus took very long to get to the plane when he said that he was going to go get food and come back. He told Hazel and her mom that the line at McDonald’s was really long but the truth came out when he was sitting on the plane next to Hazel. â€Å"Listen, sorry I avoided the gate area. The McDonald’s line wasn’t really that long; I just†¦. I just didn’t want to sit there with all those people looking at us or whatever.â₠¬  (145, 146)Here Augustus’s struggle with cancer is the looks that people would give him, looks that were just too hard to fathom. He didn’t want to get those looks. It bothered him. Augustus did not like people looking at him like there was something wrong with him. It was just mortifying. Isaac was Augustus’s friend that introduced him to Hazel. Isaac and Hazel went to support group together. Isaac suffered from eye cancer, and he was going to get a surgery that would eradicate himself of his cancer. The problem was that this surgery would steal his sight.This was a huge obstacle that cancer has set for him and he has to cope with the struggle of loosing his sight. But something even worse happened to Isaac when he told his girlfriend about the news (that he was going to be blind). His girlfriend stopped seeing him and it broke Isaacs heart. She was his true love and they said they would always be together, but she could not take it anymore. â€Å"She said she can’t handle it. I’m about to lose my eyesight and she can’t handle it. † (60) The reason his sight was going to be disdained was to loose his cancer.Meaning that the cancer was the cause of him loosing his sight, initiating the lose of his true love. This was Isaac’s huge struggle in life with cancer. Loosing the love of his life. The theme of struggles in life with cancer relates to the title because these struggles from cancer are the faults (struggles) that are in the stars, what is keeping the building blocks from becoming skyscrapers, which is initiated by the wrecking ball (cancer). Cancer is a deadly disease that constructs many problems in life.According to the love that was shared between Hazel and Augustus, no problem or â€Å"fault† would ever desist the love that these two had for each other. Augustus showed hazel that there is more to life than staying home and letting cancer consume you. It did not take long for them to fal l in love. Together they were unbeatable and they would never let anything bring them down. They both went through rigorous paths, but together, their loved steered themselves out of that hardship, and to safety. When Hazel was taken to the hospital because of her overexertion the nurse informed her about Augustus.â€Å"You’re not going to ask about your boyfriend? † she asked. â€Å"Don’t have one,† I told her. â€Å"Well there’s a kid who has hardly left the waiting room since you got here,† she said. â€Å"He hasn’t seen me like this, has he? † â€Å"No Family only. †(108) Even though it was very hard to see Hazel in that faze of discomfort, Augustus went because he loved her. He did not let hardship terminate his love for hazel. He would not let anything stop him from seeing her. When Augustus Osteosarcoma returned, he went to buy a pack of cigarettes in the middle of the night, and something went wrong with his G-tu be. He told Hazel to come and help him fix it.She took off her BiPAP, attached herself to an oxygen tank and went to help him before it was too late. When she saw him Augustus was in the drivers seat of his car covered in his own vomit. â€Å"Oh, G-d, Augustus, we have to get you to a hospital. † I gagged from the smell but bent forward to inspect the place above his belly button where they’d surgically installed the tube. The skin of his abdomen was warm and bright red. â€Å"Gus, I love you. † (244-245). Hazel loved Augustus so much that she took off her BiPAP, and left by herself with her oxygen tank to help Augustus in his urgent time of need.She did not let this â€Å"fault† bring down her spirits and she did what ever she could to keep him alive. She saved his life and if she did not go there to help him (and call 911) Augustus would not have made it. Their love triumphs through hardship, that is how powerful their love is. This theme relates to the title because the love is what keeps those stars or building blocks (peoples lives) up and running and they wont let the fault (hardship) get in the way of the love. Love isn’t something that can be wished upon, you have to have that click.The click between Hazel and Augustus was so strong that they would not let anything get into the way. At the end of the book Hazel is forced to cope with the death of her one and only soul mate, Augustus. Hazel was devastated. She loved him so much. At his funeral, she went up to Augustus’s coffin to say her last good bye. â€Å"I love you present tense,† I whispered, and then put my hand on the middle of his chest and said, â€Å"It’s okay, Gus. It’s okay. It is. It’s okay, you hear me? † I had-and have-absolutely no confidence that he could here me. I leaned forward and kissed him on the cheek. â€Å"Okay,† I said. â€Å"Okay.† (270)Hazel has been trying very hard not to let it get to her (the pain), and she does not want Augustus to be mad that he died on her. That is why Hazel says its okay, to apprise Augustus and make herself know that she can live through this. The theme of coping with the death of a loved one relates to the title of this novel because coping with the death of a loved one is another fault (struggle) that was in the stars that was initiated from death by cancer. Osteosarcoma was the wreaking ball that destroyed Augustus’s building blocks and Augustus’s passing was the wreaking ball that injured Hazel’s building blocks.There are many obstacles in life, and we always try to overcome them. Some people have it harder than others. Some people are forced to live their lives battling cancer. That is what The Fault in Our Stars is all about, the burden of living life as a different person with new problems everyday. Some days will be better than others, and some days will be worse. It’s a never-ending roller coaster. Su re there will be times where it slows down and rides along a straight path but there will always be those times where it goes fast and gets bumpy. People live today overcoming these endeavors.There are many themes in the novel that correspond with the title. The struggles in life with cancer, how love triumphs through hardship, and coping with the death of a loved one. These themes not only correlate to the title but they also portray the main idea of the story. Our lives are a set of building blocks and if we don’t learn how to eventually take and overcome the blows from the wrecking ball, we will never have that chance that all of us have always longed for (even for people who are not battling cancer), to not only become a skyscraper but to be commended as one.

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Essay on John Locke on Tacit and Unintended Consent

In his Second Treatise on Law and Government, John Locke outlines clear and coherent standards for what constitutes a legitimate government and what persons one such government would have authority over. Both are determined by citizens acts of consenting to relinquish to the government part of their natural authority over their own conduct. Unfortunately, the situation becomes much less clear once we consider how his standards would apply to the political situation existing in the real world today. If we continue to subscribe to Lockes account without altering its standards, we would see a precipitous drop in the number of people whose interests existing governments are responsible for serving. In this paper I will show that with†¦show more content†¦Someone merely travelling on a public road through a country will have less contact with the civil society of that area and so fewer laws of that society will have application to her behavior. Still, those laws that do cover wha t activities she carries out have binding force on her (II, 120-121). These people incur the obligation to submit to local authority because that authority is protecting them, perhaps by preventing the citizens of the area from acting in ways that would harm other people including the outsider. For the outsider to be free of those restraints and take advantage of the areas citizens would be unjust; therefore she is obligated to comply with the legal restraints observed by citizens the area. In neither of these cases would the person in question be considered a member of the civil society whose laws she is obeying unless she expressly consented to join that society in addition to her tacit consent to follow its laws. An immediate criticism of Lockes account thus far is that in practice, hardly anyone expressly gives consent to join any civil society. Even in most real-world cases where a person does announce submission to a particular government, the declaration would not meet Lockes conditions of consent that would give legitimacy to the rule of government over thatShow MoreRelatedOrganisational Theory230255 Words   |  922 Pages. Organization Theory Challenges and Perspectives John McAuley, Joanne Duberley and Phil Johnson . This book is, to my knowledge, the most comprehensive and reliable guide to organisational theory currently available. What is needed is a text that will give a good idea of the breadth and complexity of this important subject, and this is precisely what McAuley, Duberley and Johnson have provided. They have done some sterling service in bringing together the very diverse strands of workRead MoreLibrary Management204752 Words   |  820 Pages2007007922 British Library Cataloguing in Publication Data is available. Copyright  © 2007 by Robert D. Stueart and Barbara B. Moran All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 2007007922 ISBN: 978–1–59158–408–7 978–1–59158–406–3 (pbk.) First published in 2007 Libraries Unlimited, 88 Post Road West, Westport, CT 06881 A Member of the Greenwood Pu blishing Group, Inc