My Kind of Love Paragraph for Changing Self Essay free essay sample

Change is a constant in everyone’s lives; it’s the thing that remains while everything else transforms. In my related material of the song ‘My kind of Love’ written by Emeli Sande demonstrates just how true that statement is. In the video, Emeli visits a sick friend in the hospital, and decides to take her out to town to boost her morale, if not her health. The concept of the song was inspired by the period of time Sande was a med student. One of the things that inspired her was the patients and the interaction that they had with there loved ones during their time of illness. Because when people arrived at the hospital, money and status became irrelevant and only health mattered, which sparks an honesty between people and that’s the type of love she’s singing about. The music devices in this production are phenomenal doing everything in their power to make the listener feel. We will write a custom essay sample on My Kind of Love Paragraph for Changing Self Essay or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page A smart choice was the key she wrote the song in, she used the F minor scale, which is a scale known for passion, its key signature has 4 flats in it giving the scale an emotional edge therefore giving the song an emotional edge. In the first verse, she starts with a progressing dynamic with the piano alone and her vocals; â€Å"Sometimes the truth wont make you happy,† which is immediately making you fell the sadness of that statement. Then as the dynamic slowly builds she states â€Å"But don’t ever question that my heart beats only for,† which shows her giving her power away to then lead up to the texture of layers of instruments increasing and developing the strong and powerful chorus where she sings â€Å"Cause when you’ve given up. When no matter what you do it’s never good enough†¦Ã¢â‚¬  and the tone of her voice that she sings it in is almost a whine for the purpose of creating a more heartfelt sound. The lyrics of the chorus are gorgeous because they truly present the hurt and pain of her experience â€Å"†¦When you never thought that it could ever get this tough. That’s when you feel my kind of love. † These lyrics and the melody in which they are sung; plus the 5 other harmonies underneath her vocal, immediately pluck the strings of your heart. Like in â€Å"The Glass Jar† the writer is trying to demonstrate how you need to take a walk in their shoes for a day or a night in the persona of â€Å"The Glass Jar† and then you’ll know how they feel and how they experience things. Self change plays a huge part of this song, because she’s saying even when you have given up, and when your kind of love no one else can experience, to still stand tall and move forward she’s proving to herself how strong she is and how much she can handle even when she has given up. So its change in her inner self to take that step forward while the things around her collapse and transform. Yet, her heart still beats for the person she cares so much about and that’s how she expresses her kind of love.

The Genius of Wolfgang Amadeus Mozart essays

The Genius of Wolfgang Amadeus Mozart essays Through the hard times and financial insecurity of a musician in the 1700's, Mozart accomplished his dream of becoming a great musician. Coming from a talented family, he spent his life with music. All this started when he was old enough to walk. Wolfgang Amadeus Mozart was baptized in a Salzburg cathedral the day after his birth; January 27th, 1756. He was born to the Leopold Mozart, a musical author, composer, and violinist; and to his wife Anna Marie Pertl. Only Wolfgang and his sister Maria Anna, or Nannerl, survived infancy. Wolfgang was the seventh born child, out of seven children. Wolfgang was baptized under the name Joannes Chrysostomus Wolfgangus Theophilus. He never used these names in his later life. He often went by Amadeus or Amade. Although he could not walk until the age of three, Mozart started to display musical talent at the age of four. He could also play any piano melody given to him. It is believed that Mozart's first music was composed shortly after his fourth birthday. At age five he could play the violin with perfect intonation. He injoined this attention that he was getting for being a gifted musician. He found great pleasure in learning and pleasuring his father. It took all of 30 minutes to mast er his first musical composition. This was a scherzo by Georg Christoph Wagenseil, learned three days before his fifth birthday. Leopold began to neglect his court career and devote more time to Wolfgang and Nannerl's musical instruction. He then proceeded to send his two children on tours to play in the courts of Europe. The family set out from Salzburg on September 18, 1762. At Linz, Wolfgang gave his first public concert. Among the audience was Count Herberstein and Count Hieronymous. Both were astonished and hurried to Vienna to spread the reports of Mozart's talent. All of Vienna was anxiously awaiting the arrival of the prodigies from Salzburg. '"We are already being talked f everywhere," Leopold reporte...

Patch work for university year one student Assignment - 2

Patch work for university year one student - Assignment Example James was a determined and hardworking manager who conducted research on the ways that help bring positive results in a company. According to him, the most important was the human behavioral approach as the company’s workers were core in any activity a company undertook. He spent a considerable good amount of time learning the behavior of the four workers and coming up with ways of motivating them to work hard in order to achieve the set goals. After a close chat with Olive, James found out that she performed poorly under close supervision but performed well when given the space and freedom to work on her own. Harry was motivated by deadlines and working under a little pressure and thus all the work which had little time frame would be given to him. The unique thing about the skit is that James had to indentify on his own the behavior of the other group members and this is similar to what the managers do. It was easy for James however, to know the characteristics of every pers on in the group as we are in the same class. A manager should also find it easy to know the behaviors of his or her workers as they are working together all the time and for an extended period. I have grown up thinking that attaining skills that enable an individual work in a certain career line is all that an individual needs to become successful but my view changed after reading the article on continuing professional development (CPD) (Scales, 21). The article states that due to the ever-changing dynamics in the world, mere skills and knowledge in a certain career field are not enough and that a professional needs to continue developing them. I was amazed by how simple a professional could continue developing in his or her related field. According to the author, the first step to this is documenting and keeping track of the knowledge, experience and skills that a person has. It had not hit

SWOT Analysis - NYLB Research Paper Example | Topics and Well Written Essays - 3000 words

SWOT Analysis - NYLB - Research Paper Example This function started since 1909 after the New York legislation passed a law which stated that the receiver would have separate responsibility and was appointed by the State Supreme Court of New York (New York Liquidation Bureau, â€Å"Home†). Mr.Bing, chief executive officer of the NYLB authored 85 bills that passed the Assembly and around 35 of the bills passed the senate and were signed into law. Among these law included the 2006 law passed by Mr.Bling which stated about the limitation of workers, recovery and clean up workers, compensation claims made by the 9/11 rescues; other law stated were the 2010 no fault divorce law, adoption of the UPMIFA statute in 2010, the law of criminal and civil penalties in the year 2008. Apart from the law stated above the chief executive also authored laws for the insurance and real estate sector so that these industries could taste success even during hard economic times. NYLB performs administrative and operational support to NYLB through economical and timely procurement of goods and services. The claims division looks after the disposition of claims which meets the criteria under the New York Security Fund, enabling NYLB to close its proceeding of estates with the allocated time. The creditor and ancillary division looks after the insolvent users and helps the Superintendent performs his responsibilities. The assets of NYLB are looked after by the finance division and the Human Resource department protects the estates by minimizing the risk (New York Liquidation Bureau-a, â€Å"About us†). The bureau does not own any assets, rather it holds and manages the assets of the security funds and estates and acts as a fiduciary for the benefits of the creditors and policyholders of the Estates. The Bureau’s total receipts for the year 2010 stood at $ 195,486,151 as compared to 2009 of $ 100,186,041 and net receipts was much higher as compared to previous year and was calculated to be $15,588,520. Cash comprised only the money which are deposited in the CDA and for longer term investment opportunities the cash is placed in the Money Market Deposit Account so that a more attractive yield is achieved. The bureau monitors the cash balance based which are in excess of insured limits and based on the information, such balances does not represents material credit risk for the New York Liquidation Bureau. Thus cash at the beginning of the year 2010 accounted to $15,022,557 and for 2009 cash was $7407191 and cash at the end of the year accounted for a total amount of $30, 611,077 in 2010 and $ 15,022,557 at the year 2009 (NYLB-c, p.3-4). Literature review The New York Liquidation Bureau performs the responsibility as a Receiver for the Superintendent of Insurance and the Bureau acts on the behalf of the superintendent in order to carry out the duties to safeguard the interest of the creditors and policyholders of the insolvent a nd impaired insurance companies. The Bureau takes care of the insolvent insurance companies in order to maximize the assets and resolve the liabilities, return back the rehabilitated insurance companies to market place so as to distribute the proceeds of the company to the creditors within the given period of time. NYLB has been performing the function of the Receiver since 1909. When the insurance company is

Photography Essays Bernd and Hilla Becher

Photography Essays Bernd and Hilla Becher Identify what you consider to be the legacy of the artist Bernd and Hilla Becher for the importance of the photographic image. ‘The modern photographer is the architect’s greatest publicist’; that is, if one considers architectural photography a dumb copying device, and a pure record that informs the onlooker only of the building and its functionality.   However banal a series of photographs depicting only water towers may seem, Bernd and Hilla Becher dedicated much attention to photographing such icons of post-war Germany and so created a historical document.   In this way, the Bechers’ living legacy is ‘a narrative of socio-historic reality based on photography’s potential to retain some indexical trace of its subject’, but as mentioned by Mack, the Bechers are amongst those photographers who are also ‘involved in some level of construction or fabrication, distinct from the realist and objective position which is usually attributed to [photography]’.   Their photography and teachings represent a time when photography was winning serious cons ideration by the European art scene and so are undeniably important and influential, but perhaps the most pointed question to ask of their work is the exact nature of its influence on other artists, on the nature of the photographic image, and on the landscape of Germany of which the mine shafts and silos they photographed were a vital part. Just as an historic text is the subject of the author’s interpretation of the reality of the times, a photograph is the product of the photographer’s choice and manipulation of an image.   It is plain that the Bechers were not attempting to flatter architects or approve of the design and function of the buildings they photographed, as is often the case in the classic understanding of architectural photography.   Although it cannot be denied that their many images, like those of August Sander, create a social document for posterity’s sake, the photographs are in no way a sentimental harking back to the past or a reassurance of German identity.   The technology depicted in the Bechers’ typological sequences, often in a state of deterioration or abandonment, could be said to represent a time of spiritual poverty and the ‘erosion of inherited cultural and moral values’.   In light of this suggestion, Bernd and Hilla Becher seemed to be see king to document their subjects in a clinical, objective manner; remaining fascinated with but shedding the past in the hope that ‘the unburied industrial sources of Modernist imagery be sanitized and distanced from us, lest [they]†¦ invade the minds of another generation’.   Therefore, unlike August Sander, the Bechers are more interested in showing us death (rather than Sanders life study of the classes of Germany); the photographs can be said to be looking ahead to a better future only if the viewer interprets it so. Shouldnt these photos then, fascinated by death to the point of necrophilia, be filed away and forgotten?   Rather, it should be said that the photos enlarge our understanding of the photographic image, precisely because they serve as a stark reminder of a past away from which the world has moved.   As much as it was tactful for German artists to deny history in the immediate post-war period, Bernd and Hilla Becher chose to show it, with characteristically functionalist honesty and truth.   Viewing the photographs, we know that the spiritually repressive time to which the buildings belong has passed and so view our position favourably.   Photography is the art form that is most closely comparable to our reality; whether they meant to or not, the Bechers have created art through which we view history with a clarity that cannot be gained through memory or other art forms. Photography has always been associated with some notion of cutting out and keeping the past in order that it is not forgotten, although not necessarily in order to commend or legitimate the events therein.   An extensive collection of nakedly truthful architectural portraits such as the Bechers’, could be said to be a way of preserving the buildings and what they represent, rather than a way of banishing them to ‘the registers of the dead’ in order that society moves forward (or at least away from the faux progression of industrialisation).   Preservation, yes, and as important to the renewal of German identity as is the conservation of Auschwitz.   Indeed, the Bechers were heavily involved in the German industrial preservation movement that started in the 1950s and resulted in numerous icons of the country’s economic and cultural history being listed and their demolition prevented.   The power of the Bechers art, and therefore part of their renderi ng of photography as an important form, is tangible in that the photographs were so compelling that they became a part of a movement which changed (or maintained) Germany’s landscape. It can also be said that, in preserving the winding gear, the framework workers’ houses and silos in their art, the Bechers’ ‘industrial archaeology’ was an investigation into specific communities.   Despite claims that their subjects are completely isolated from their environment, the photographs are often dated and their locations documented, and therefore offer a pertinent reminder of a specific space and time for each similar but significantly different image.   From there, a viewer can take time to study the stilled physicality of the buildings, their silent watch, whilst remaining aware of their specialised existence within individual societies. Whilst this is a large part of the Bechers’ typological studies’ legacy, their way of showing buildings is most certainly not anthropocentric.   Never do they purposefully use the human form to legitimise or enrich their industrial subjects.   Indeed, it is the very absence of the human form that makes these photographs so interesting because actually ‘the handiwork of men is everywhere visible’ and the collection stands partly as a testimony to humankind’s inexhaustible ingenuity and inventiveness.   The Bechers’ fascination with metal and all that goes with its production could not be a more powerful statement about that which is alien to human fleshly existence, but in the same way it is a comment on the extents to which industrial people are forced to go because of their reliance on the laws of nature. Not directly interested in the human form, but nevertheless a product of the human mind and skill, the Bechers’ art shows humankind’s flagging attempt to master nature, to reign it in and use it or, indeed, to ‘make nature in the image of their own desires’.   Such a battle can only end in failure as, with water towers for instance, the very function of the buildings remind us that we are utterly reliant on the earth’s resources; only when we combine our understanding of forces such as gravity with our desire to remain alive are we able to create technologies that serve us whilst abiding by nature’s laws.   In so saying, it is interesting to note that the static image of the photograph reminds one of the denial of evolution.   The Bechers help the viewer see, through their almost exhaustive collection of similar images, the differences between the humans self and the buildings in the photographs.   The most pointed distinction being ho w each succumbs to the processes of evolution.   Whilst we move on from war, from old ideas about art, from economic peak to economic trough, these buildings stay very much the same.   This becomes part of the distancing process that seems to make the Bechers’ work so important; the photographic image is unchangeable, undeniable truth that will always remain in the past whilst we move on ourselves.   The photographs come to deny the ‘progress’ they originally stood for, and so reaffirm our place in the present and, more importantly, suggest our continuation into a future that will be different. The Bechers’ work has received much attention; even winning a prestigious prize for sculpture.   The framing of the photographed buildings, the uniform lighting used and the subjects’ apparent freedom from their visible environment allows a neutralisation, which brings the buildings closer to sculptural treatment than the two-dimensional reportage that is often the lot of the photographic image.   As Klaus Bussmann states in his introduction to the Bechers’ Industrial Faà §ades; ‘in these photographs the function of the architecture does not emerge from its form’.   Unlike the art of the Neue Sachlichkeit, the Bechers’ photography does not celebrate the ‘dynamic and dramatic functionality of the industrial machine’; indeed it does not invest them with any meaning at all.   We invest them with meaning and memories – but the Bechers were seemingly fascinated by their deadness, their static place in history and their comparison with the vibrancy of human existence. The Bechers’ work made a remarkable impact on the art world, and the affect of their legacy is partly due to the manner in which they chose to display their photographs when their work was exhibited.   If there is an argument that depicts the photographic image as a bland record of what we can all see as it exists or existed in nature, then the Bechers’ typological constructs deny this.   Seen in groups; one building in comparison to a dozen others of almost (but pointedly not) identical appearance, the subjects of the photographs are recreated anew, and suddenly become something other than their pure physicality.   The viewer is irresistibly invited to take note of those differences, to see the similarities and variations all at once – are they impersonal or not, beautiful or ugly?   Seen together, the images become a greater challenge to the viewer’s notion of banality, of universality and the fundamental core of human needs. Alongside their fellow post-war photographers, the Bechers recreated photography as an art form, which is as legitimate as any other.   Their subject matter is not directly passionate, does not reveal the interior workings of the photographers’ identity and does not even deal with emotional issues, as is the common arena of the art world.   Instead, their calm, measured series of photographs introduces a part of western industrial society in the most honest way.   Because of its closeness to our experience of reality, we react very deeply to photography; the experience of looking at a framed portrait is intensely emotional whether the subject is treated in an emotional manner or not.   The legacy of the Bechers runs deep, especially in light of their teachings at Dà ¼sseldorf and the photographers who have come after them.   Bernd and Hilla truly understood the power of photography and have had a hand in investing the medium with the ‘power to influence our pe rception of the world around us’.   Their legacy is complex and the personal reaction to their work can be confusing as one finds a fascination with the deadness of their subjects at the same time as being instilled with some semblance of hope for the future.   Their ‘industrial archaeology’ will remain with us to aid the excavation of man-made landscapes and, indirectly, lead to a better understanding of the human condition. References Becher, B.  Ã‚   Tipologie, Typologien, Typologies – Bernd and Hilla Becher.   Munster: Klaus Bussmann, Bonn: 1990 Becher, B.   Industrial Faà §ades – Bernd and Hilla Becher.   Cambridge, Massachusetts: MIT Press: 1995 Becher, B.   Water Towers – Bernd and Hilla Becher.   Cambridge, Massachusetts:   MIT Press: 1988 De Mare, E.   Architectural Photography.   London: B T Batsford: 1975 Gillen, E (ed.) German Art from Beckman to Richter: images of a divided country.   London: DuMont: 1997 Homburg, C (ed.) German Art Now.   London: Merrell: 2003 Honnef, K Sachsse, R Thomas, K (eds.)   German Photography 1870 – 1970: power of a medium. Cologne: DuMont: 1997 Mack, M.   Reconstructing Space: architecture in recent German photography.   London:   AA Publications: 1999 Robinson, C Herschmann, J.   Architecture Transformed: a history of the photography of buildings from 1839 to the present Cambridge, Massachusetts: MIT Press: 1987 Rosselli, P. (ed.) Architecture in Photography Milan: Skira: 2001 Sander, A.   August Sander: citizens of the twentieth century: portrait photographs 1892 – 1952.   Cambridge, Massachusetts: MIT Press: 1986   http://www.arts.monash.edu.au/visarts/globe/issue6/dptxt.html   31.03.05

Herrick: Delight In Disorder Shows Delight In Life Essay -- essays res

The lively figures of speech in Herrick’s â€Å"Delight in Disorder† show his sensual delight in the little things in life. The oxymorons, animations, images, and paradox in this poem display the author’s enjoyment of true uniqueness. The animations in â€Å"Delight in Disorder† show how the speaker sees the clothing as having a will of it’s own that makes the outfit more â€Å"bewitch[ing]† (13). For example, the author cites a â€Å"tempestuous petticoat† and a â€Å"careless shoestring† as things that cause the woman’s dress to be unique and intriguing (9, 10). Through his use of the animation â€Å"tempestuous petticoat†, the author shows the reader that the petticoat not only flows freely and wildly, but the woman is also free and wild (9). The â€Å"careless shoestring† shows the how the disarray of the woman and her...

Barrows and Pickell model of problem solving Essay

INTRODUCTION This is a case study concerning a patient presenting with low abdominal pain, frequent micturation and dysuria. I will discuss the consultation and show how I used the problem solving consultation style detailed by Alison Crumbie. This involves listening to the patients’ initial complaint and developing hypothetical diagnosis. Focused questioning and clinical examination and investigations will then be used to eliminate some of the initial hypotheses. The patients’ perspective of their problem will be addressed and the synthesis of gathered information will enable the practitioner to arrive at a differential diagnosis and to agree on a treatment plan with the patient so that they can manage their problem. I currently work as a Nurse Practitioner in General Practice in East London. I provide first contact appointments for patients registered with the practice each morning on a walk-in basis. I am a non medical prescriber and generate prescriptions for patients. I work autonomously within my agreed scope of practice and am supported by the structure of a small organisation of professional clinical and administrative staff. The patient , whom I will call Sue, presented in the walk-in Surgery and told me she had had three days of stinging pain on passing urine, increased frequency of passing water and intermittent low abdominal discomfort. She also said that she had a water infection three months previously and that she thought that she now had the same problem. She had tried over the counter (OTC) medications and had increased the amount of fluids she drank with little effect. She said that her abdominal pain reduced after taking paracetamol but reoccurred after a few hours. She requested a prescription of the same antibiotics she had last time she had this problem. Forming the initial conceptMy first impression of Sue was that she was smartly dressed, of normal weight, looked physically well and did not appear to be distressed. She attended alone and I could see from her patient record that she was 25 years old. After introducing myself I asked her two opening questions – ‘how can I help you’ and ‘what brings you here today’. I find by combining open and closed questions in this manner it helps the patient be more focused on their presenting compliant than by using either of these  opening questions alone. I try not to interrupt the patient as they respond and so give them the opportunity to relate what they think the problem is and what it is they think I can do to help them manage this problem. Sue told me that she got a burning pain on passing urine and thought that she had cystitis. She told me that last time she had a similar problem she was given antibiotics tablets. Sue told me that she had tried to self manage with OTC medications for pain relief and for cystitis for the past 2 days but had had no lasting relief from symptoms. She said that a few hours after taking paracetamol her pain returned. My initial concept was of an articulate, well dressed woman, who had decided that she was experiencing a urinary tract infection (UTI), who had tried unsuccessfully to manage her symptoms her self and was now requesting assistance from a health care professional. She appeared systemically well to me but possibly had cystitis. Generating multiple hypothesesA provisional explanation for the patients’ problems could now be attempted. It is important to think as widely as possible about potential causes to generate broad hypotheses which can then be narrowed down with focused enquiry and investigations (Crumbie et all) The quality of hypotheses is dependent on the practitioners experience in eliciting information from the patient and in translating this information into a number of potential scenarios. It is important that the information offered by the patient is understood correctly and not translated badly by the practitioner. For example a patient may say they felt sick and the practitioner understands this as feeling nauseated whilst the patient meant they felt generally unwell. I hypothesised that Sue could be suffering from Cystitis (uncomplicated UTI) , pylonephritis (ascending UTI), eptopic pregnancy, Pelvic Inflammatory Disease (PID), Sexually Transmitted Infection (STI) or constipation. On later reflection I realized I could have though about interstitial cystitis, appendicitis and renal calculi. My multiple hypotheses for this patient are presented in Table 1. Formulating an Inquiry StrategySue had told me that she had pain on passing urine and as I focused my questioning she told me her urine appeared darker in colour than normal and smelled different than usual. She described the pain as stinging and said that it was provoked by micturating and relieved a minute or so after she stopped urinating. I asked her to point to where the pain was in her abdomen and she indicated the suprapubic region. She gauged the pain to be level 6 on a pain scale of 0-10 without analgesia but did say it was relieved by analgesia and resolved to a feeling of pressure rather than pain at that time. Back/loin pain, nausea, vomiting, fever and frank haematuria are all more common with pylonephritis. Sue denied any of these symptoms which made it less likely as a diagnosis ultimately. .On enquiry Sue told me that she used Depo- Provera injections for contraception and dysmenorrhoea and consequently did not menstruate. She also denied any spotting of blood. Her last injection was given in practice 40 days previously and by reviewing her notes I could see her history showed timely attendance for these injections. Although I knew that both dysuria and suprapubic pain can be experience in both normal early pregnancy and in eptopic pregnancy, and that cystitis is more common in pregnant women, I felt I could now discount pregnancy as a cause of her symptoms due to her contraceptive history. I then asked her about her sexual history. Sue told me that she was currently celibate and had not had a sexual relationship for one year. I She told me she had never experienced genital herpes so I felt able to discount STI at this stage. I enquired about her bowel habits and Sue told me that she had passed a soft stool that morning as was her normal routine and that there had been no recent change to bowel actions. This made a diagnosis of constipation less  likely. Whilst enquiring about her symptoms I used Mortens PQRST structured clinical questioning mnemonic. This enabled me to focus my questions and to analyse symptoms and Sues responses. It is especially useful when assessing symptoms of pain and enabled me to detail a focused history of her complaint. I have used this technique extensively since commencing Nurse Practitioner training and have found it easy to remember and that it adds a structure to my questioning that was previously lacking. Incorporating the patients perspectiveFollowing the above questioning, I went on to discuss with Sue her own concept and concerns regarding her presenting complaint. I asked Sue what she thought was causing her problem, what she thought was required to rectify the problems and what could help prevent reoccurrence. She told me that she was sure that she had another episode of cystitis and that she needed antibiotics. Applying appropriate clinical skillsI began with a general inspection of Sue’s external appearance ,her tone of voice and articulation. I recorded her vital signs. She was apyrexial @ 35.6 Celsius and normatensive @ 120/70. Respiratory rate was 12/min and pulse rate 80 bpm. These results are within normal limits for a person of her age. I performed near patient testing in the surgery with urine dip stick testing. This showed a positive response to nitrates and leukocytes. I did not have facilities for near patient pregnancy testing, and on reflection would not have performed one at this time in this case due to her contraceptive history. I chose not to send a test off to the laboratory for pregnancy testing for the same rational. Sue declined an internal exam at this time. I noted from records that Sue had not had a smear test so I offered to do this at this time. After explanation Sue agreed to this. I asked Sue to undress from the waist down and to lie on the examination coach. I ensured that she was comfortable screened and relaxed before commencing the exam. I examined her abdomen using the process taught in Nurse Practitioner  training and described by ( Bickly 2005). I noted her abdomen was of normal appearance with what appeared to be an appendicectomy scar. Sue confirmed that she had had her appendix removed as a child. I auscilated for bowel sounds in the four quadrants and as these were heard and of normal tone I was able to rule out an acute abdominal problem. I then percussed her abdomen and found no change to expected tympani. This helped confirm the patient’s opinion that she was not constipated and after palpation of a soft abdomen I was able to discount this hypothesis at this stage. When I palpated her suprapubic region Sue complained of discomfort, this tenderness is indicative of bladder inflammation. Palpation of the costovertebral angles induced no pain response from Sue and as I recalled her vital signs and presenting history I felt able to exclude pylonephritis also. I then began an exam of Sue’s external genitalia looking for swelling, ulcer, lacerations or discharge. Inflammation and discharge are common with Candida and other vaginal infections. Genital herpes causes ulcerated areas and scratching can cause minor skin lacerations. This external exam was normal. I continued with the vaginal examination. Using a bimanual technique I first felt for Sue’s cervix and palpated it from side to side looking for a positive chandelier sign. If there is infection in the uterus this test can elicit pain. Sue did not have any pain on testing. I then inserted the speculum and examined the vaginal walls for signs of injury or discharge. This was also normal, inspection of the cervix and of the os showed no discharge and this combined with a negative chandelier sign now made the diagnosis of pelvic inflammatory disease less likely. I performed a smear test and took samples for HVS and Chlamydia testing. My initial hypotheses of cystitis now seemed most likely as the cause of symptoms. During this examination sequence I was reminded to consider appendicitis as a hypothesis in the future with this set of presenting symptoms. Developing the problem synthesisWhen I considered the presenting problem, my history and examination findings, and compared them with my original hypotheses I found that I was able to eliminate some at this stage. As Sue had no fever, nausea, haematuria or costovertebral pain I discounted pylonephritis. Bowel history and examinations were normal so constipation was also discounted. As Sue had a record of in date contraceptive cover with an injectable contraceptive and denied sexual intercourse I discounted pregnancy. Although I was aware that Pelvic inflammatory disease could account for her symptoms, examination findings had not supported these hypotheses and were all negative at this stage. When I reviewed the consultation at this stage, recalling the positive urine dip test, the suprapubic tenderness and the patient’s history I was able to be confident that to proceed with the differential diagnosis of cystitis was most appropriate. Diagnostic decision makingMy differential diagnosis was cystitis .I made a differential diagnosis of cystitis for the following reasons:Previous episodeDysuria – pain on micturation and frequencyLow abdominal pain – provoked by palpation of suprapubic areaNo systemic signs/ vital signs normalNo red flags – haematuria, pregnancy, recent change of sexual partnerPositive urine test for nitrates and leukocytesTherapeutic decision makingSue had come to surgery with the idea the she required antibiotics to treat her self diagnosed cystitis. She wanted her health care provider to facilitate this request. She had tried self management and used OTC preparations before presenting in surgery. This showed me that she was motivated in trying to achieve resolution of her problem. As these measures had not been successful in this instance we could agree a short course of oral antibiotics would be an appropriate treatment plan. As I had access to Sues health record I could see that she had been prescribed trimethoprin previously. Sue confirmed that she had no side effects from this medication and that she was willing to take it. As there were no contraindications for  prescribing trimethoprin for this patient I issued her with a prescription for 1 x 200mg tablet, twice a day for three days. This is in line with prodigy guidance and local prescribing policy. As this was the treatment plan Sue had originally requested I was confident of concordance. I discussed with Sue some steps she could take to try and prevent reoccurrence of infection. These includes toilet hygiene (front to back wiping), post-coital micturation, regular voiding and reiterated early symptom self help measures with increased fluid intake and OTC cystitis remedies. I also provided Sue with a printed Patient Information Leaflet about self help measure for women with cystitis. I advised Sue that she should find her symptoms improving within the next 24 hours and asked to return to either the practice or the NHS Walk in Centre (depending on hours of opening) if she had no improvement in 48 hours or if her symptoms changed and she became feverish or pain increased. I explained that these could be signs that the infection was moving up towards her kidneys and that this would require urgent review. I explained that I had given her an antibiotic which would work for the majority of infections but that on some occasions is not effective and a different antibiotic is necessary. I provided her with this information so that she could make sense of any change in symptoms and would be more likely to present earlier for a consultation with a health care professional if there was treatment failure. Reflection in and on practiceI felt that this was a satisfactory consultation for both the patient and me. It began with the patient stating that she thought she knew what was wrong with her and what action needed to be taken to resolve the problem. By listening to the patient’s story I was able to make an analysis of her responses and to think of a number of multiple hypotheses. Proceeding with focused inquiry and utilizing clinical examination skills enabled me to discount some of these hypotheses, and by using structure, reminded me of hypotheses I had originally forgotten to include. I was able to facilitate an unexpected health intervention when the patient and carry out  opportunistic smear testing. Following on from this I was able to reach a diagnostic decision and make therapeutic interventions. Throughout I was communicating with the patient, offering education and involving her in her care which should translate to better concordance with treatment plans and improved patient satisfaction with the consultation. This consultation took me 18 minutes to conclude and although I feel that I covered a wide range of potential hypotheses concerning the initial complaint and responded effectively to the patients concerns, I did feel time pressured. On reflection I need to be able to balance the quality of the consultation with the quantity of patients requiring attention during a session. I could have asked Sue to book another appointment for a smear test which would have enabled me to manage my time better but at the expense of patient distress and an incomplete patient episode. It has been my experience to be critisised by my medical colleuges about the time taken for consultations and they are in fact able to move patients through the surgery quicker than I can. Although this is a recurrent problem I believe that the most prevalent reason for this is that in using this model of consultation the practitioner addresses a wider range of potential hypotheses and that these can lead on to other health issues which then need addressing as demonstrated above. When I discussed this with my GP mentor he said that he would have probably tested her urine first and as it was positive for infection, prescribe an antibiotic after enquiring about her risk of pregnancy and not have addressed any other history at that stage. If he had wanted further testing, he would have asked her to make a nurse appointment. It would be interesting to see which approach is preferred by the patient and most satisfactory for the clinician. ConclusionThis case study looked at a consultation where a patient presented with possible cystitis and requested antibiotics. After following a structured consultation and diagnostic style I was able to reach agreement with the patient and to provide a prescription for antibiotics. This was a satisfactory conclusion for both the patient and me. I was also able to  address a secondary health enquiry and opportunistically provide a smear test which was of additional benefit for the patient and the practice, as auditing will show this patient to now have had a smear test which has positive financial implications for the practice.