Mr. Y is a 47 year old, mixed race [Asian/African ethnicity], male patient who presented to your office with severe right great toe pain. Onset of the pain was 2 days ago. Mr. Y denies any known trauma to his right foot or his great toe on that foot. His right great toe is red and became so swollen in the last day that he cannot put on his shoe.
Mr. Y has a history of hypertension for which he is taking HCTZ 25mg daily, Metopralol 50 mg twice daily, and Lisinopril 10 mg daily. He denies any other medical problems. Results of the lab tests that were ordered: Sed rate — 93; Glucose, random —117 mg/dl; Hgb – 13.4 gm/dl; WBC — 8200/ccm with normal diff; Serum uric acid —10.9 mg/di; Serum creatinine — 1.2 mg/d1
Assignment Questions 1.Based on presenting symptoms and lab findings, what is most likely diagnosis that will be made for Mr. Y? 2.What is the anticipated pharmacologic plan for managing Mr. Y’s acute pain? Provide a justification for the plan including a citation from a peer-reviewed source. 3.What is the anticipated pharmacologic plan for long-term management of Mr. Y’s diagnosis? Provide a justification for the plan including a citation from a peer-reviewed source. 4 Identify the key elements of the education plan that would be appropriate for the patient about the acute and chronic pharmacologic plans you identified above.
Laurence Sterne’s Tristram Shandy dominated the London literary marketplace during its serial publication from 1759-1767. Like his contemporary writers, Sterne engages in debates concerning what we would now regard as the disciplinary boundary between literature and philosophy which has established its canonical status as a work of postmodern fiction. It is difficult to ascribe, as many scholars have, to Tristram Shandy the title of ‘postmodern’. To characterize this novel through a future literary movement which defines itself through the rejection of the principles of the previous movement is incongruous. How can a novel which precedes postmodernism by over a century and a half reflect the cultural and political formations which sparked the movement itself? However, Tristram Shandy does contain fictional and narrative elements which clearly invite comparison with the fiction of the postmodern movement. Born into the Augustan Age, Sterne’s discordant writing makes him seem out of place in his own era Differing drastically from the contemporary imaginative literature of Defoe, Richardson and Fielding and the philosophical writing of Johnson, Tristram Shandy has been explained by critics as an example of ‘process writing’, a text presented in the very act of creation and change. This analysis can be applied to Sterne himself; moving away from the Augustan poets and the sentimental writers, Sterne’s writing is termed postmodern because it is a rejection of realism, turning from the objectivity of external truth to examine inner states of consciousness. Sterne’s novel clearly exhibits the postmodernist theory of metafiction, in which the writing self-consciously points to itself as an object in order to question the relationship between reality and fiction. Sterne was certainly not alone in critiquing methods of narrative construction and exploring the fictionality of the external world, but what sets Tristram Shandy apart from its contemporary fiction is the use of language as an arbitrary system. The elements of Tristram Shandy which inspire comparisons with the postmodernist movement are clear: questioning the relationship between text and the self, and an argument for the constitutive power of language. Postmodern scholars question the fundamental representation of identity and history itself, that is, history as what ‘really’ happened as opposed to history as an objective ‘narrative’ of what happened. Sterne has a clear understanding of how some element of self-definition and identification is involved in the fictional writing process, and freely admits the element of autobiography in his writing. ‘Tis … a picture of myself’ he tells David Garrick in regards to Tristram Shandy (Letters 87). The autobiographical element in Sterne’s writing suggests multiple definitions of the same reality, which depend upon perspectives rather than objective truth. This comes across as a convoluted and fragmented narrative that confuses fiction and reality, narrative and truth. Tristram himself says of his father’s masterpiece, the Trista-paedia, ‘My father spun his, every thread of it, out of his own brain, – or reeled and cross-twisted what all other spinners and spinster had spun before him’ (Sterne 93). Sterne, like his character Tristram, spins his own narrative in an intricate and complex web, so convoluted and transparent that it is difficult to tell where it ends and he begins. Tristram Shandy clearly embodies this ambiguity between reality and representation through language. James Swearingen writes that in Tristram Shandy ‘language does not just facilitate communication: it establishes the phenomenal horizon in which speakers and things spoken about are constituted’(Swearingten 117). Tristram constructs his biography through textual language, which reveals itself to be an ambiguous rather than a concrete medium. He admits that he is better associated with the text itself than the subject to which it refers. Tristram’s escape from his inevitable death is described as a journey in which ‘life follows the pen’ (Sterne 754). Once again returning to the autobiographical element of Sterne’s writing, if Tristram’s journey follows the pen, then he, like Sterne, is creating and documenting his own existence, shaping his narrative according to his liking rather than according to objective truth.>