Small Scale GTL (STG Plus) Plant

Small Scale GTL (STG Plus) PlantCourse intrinsic Gas Processing engineering (ENCH 609, Winter 2017) drift TITLEGTL Syn fellate to Gasoline (STG Plus)Professor Dr. Nashaat NassarList of figures and tablesFig 1. Schematic sketch of the STG+ system (from Primus unripe Energy TM) .. (6)Fig 2. Sensitivity Analysis for case 62.5 MMSCFD (14) send back 1. Economic Indicators for invent evaluation (Detail calculation in Appendix).. (15)AppendixFig 1. Operating GTL plants on the world map The Oil Gas Year, 2015 . (21)Fig 2. example flow chart developed for the project (from Aspen plus V 7.2 Microsoft Visio 2010) (22) display panel 1 Used compounds and Values of yields for nuclear reactor 4 in the pattern . (19-20)Table 2 Economic Evaluation for case 1 10 MMSCFD ..(23)Table 3 Economic Evaluation for Case 2 62.45 MMSCFD (24)Table 4 push-down list balance of streams 1-22 for Case 1 10 MMSCFD .(25-26)Table 5 Mass balance of streams 1-22 for Case 2 62.45 MMSCFD .. (27-28)AbstractThe worlds energy demand is growing exponentially and to meet this demand, bringing new supply sources to the market is extremely critical. Natural gas resources atomic number 18 plentiful, geographically diverse and currently overly the cleanest burning dodo give the sack. Gas to Liquids (GTL) is a chemic act that transforms subjective gas or other gaseous hydro coulombs into towering quality liquid products that would otherwise be produced from naive oil Shell Global. GTL creates an additional opportunity to monetize a countrys resource of rude(a) gas by turning them into mellow quality liquid force come knocked out(p)s. GTL products argon colorless and odorless hydrocarbons with very low level of impurities.The purpose of this project is to simulate a small scale GTL (STG Plus) plant that transposes 10 MMSCFD of rich-methane natural gas into 672 gun barrel/day of gasoline. The first step of the STG Plus mould is called move reforming and it consists of the reaction betw een the methane in the natural gas with abundant water. The second step of the growth is the reaction between the hydrogen, and the carbon monoxide producing methanol. The methanol thus formed pass on be converted to dimethyl ether (DME) and finally, the DME impart be dehydrated, producing gasoline. The project lead also highlight the difference between two major GTL technologies Fischer Tropsch and STG Plus. An economic evaluation was conducted to check the viability of this process and at 10 MMSCFD conversion of methane the project proves to be economically profitable, with an NPV value of $14.66M at 10% discount rate. It was also determined that if the merchandise of gasoline increases to over 4,100BBL/day, the profitability of this project will increase significantly.1.0. Introduction 1.1. GTL Technology and the WorldGasoline to Liquid (GTL) is a technology that converts natural gas or other gaseous hydrocarbons into high quality liquid products like gasoline or diesel moto r fuel, otherwise produced from unsmooth oil . GTL products are colorless and odorless hydrocarbons with very low level of impurities. Refineries can also use GTL to convert some of their gaseous hydrocarbon waste products into valuable fuel oil which can be used to generate income.The worlds first commercial GTL plant was opened by Shell in Bintulu, Malaysia in 1993. In 2011, the largest GTL plant, Pearl GTL was opened in Qatar Shell Global. Figure 1 in the Appendix shows all operating GTL plants and their turn backing locations on the world map.1.2. GTL OriginIn 1920s, when Germany found itself short of petroleum but with ample reserves of coal, GTL and Coal-to-Liquids (CTL) technologies were pioneered using a process known as Fischer-Tropsch (F-T) discount (Heng et al. 2004). Methanol-to-gasoline (MTG), Mobils synthetic gasoline process, establish on the transformation of methanol to hydrocarbons using zeolite accelerator pedals, was the first major synfuel process developmen t in half a deoxycytidine monophosphate since the development of the Fischer-Tropsch process (Frerich J. Keil, 1998).1.3. Gas-to-Liquid (GTL) technologyGas to Liquids (GTL) is a refinery process that converts gas or other gaseous hydrocarbons into products with longer carbon chains. Gasoline and diesel fuel are classic examples. Gases with a high concentration of methane are transformed into liquid synthetic fuels chase two methods direct transformation using processes without the front man of catalysts that convert methane to methanol or by using syngas as a midway product, such as in the Fischer Tropsch, Syngas to Gasoline Plus and Mobil processes.This project will focus on designing a small scale Syngas to Gasoline (STG) plus plant that uses methane rich natural gas as render and converts it to high quality gasoline and other products.2.0. Syngas-to-Gasoline plus (STG+) processSTG+ process was derived from the MTG (Methanol-to-Gasoline) process, which was developed by Mobil in the 1970s. This technology directly converts natural gas-derived syngas into drop-in gasoline and jet fuel through a catalytic thermo-chemical single-loop process that minimizes complexity, improves product quality and yield. The plus in STG+ stands for the alternate end products yielded by the process.The STG+ technology is currently operating by Primus commons Energy company in Hillsborough, New Jersey at pre-commercial scale with a production of 100,000 gallons (approximately) of distinct quality gasoline per year from natural gas with surpassed performance of the STG+ system and catalyst and 720 hours of continuous operation. The STG+ process consists of the following operating steps in one continuous process loop. It comprises of Syngas generation by move reforming method, four fixed bed reactors in series and a two phase separator.Figure 1 Schematic sketch of the STG+ system (from Primus Green Energy TM)2.1. Syngas Generation by go reforming methodThe first step in the S TG+ process is to convert the natural gas feed into syngas or deductive reasoning gas which is an intermediate gas feed for many dissimilar petrochemical processes. This processing basically removes contaminants, such as mercaptans, sulfides, mercury and any others that can compromise the conglomerate catalysts performance that are used in the STG+ reactors before it is fed to the syngas generation unit. Either partial oxidation or steam reforming processes are used for syngas production.Steam reforming process is widely used to generate syngas for feedstock in different petrochemical processes. A mixture of hydrogen, carbon monoxide, carbon dioxide, and unconverted methane and steam are formed when methane reacts with steam in the presence of a catalyst such as Nickel or Rhodium at high temperature (800-1000 C), high pressure (20-40 bars) and steam-to-carbon ratio variable between 1.8 and 4 in the steam reforming process which is highly endothermic in nature (Mbodji et al., 201 2).The possible reactions areThe steam methane reforming reaction (SMR)CH4 + H2O CO + 3H2 H = +206 kJ mol-1 (strongly endothermic).. (1)The water-gas shift (WGS)CO + H2O carbon dioxide + H2 H = -41 kJ mol-1 (moderately exothermic) . (2)The product from the reformer depends on the operating pressure temperature, composition of the feed gas, and the proportion of steam fed to the reactor. The thermodynamics and kinetics of the reaction within the reformer decides the amount of carbon monoxide in the final product from the steam reformer (Larminie Dicks, 2000).2.2. Reactor 1 (Methanol Synthesis) outward-developing compressors are used to compress the syngas from reforming unit which enters the reactor 1 containing copper zinc as catalyst and the following reaction occurs.2H2 + CO CH3OH H = -92 kJ mol-1 .. (3) callable to the exothermic nature of the reactions, low temperatures favor conversion to methanol and pre- pepperinessing of the reactant gas and heating of the boiler feed water are done by this special heat. The position of the equilibrium depends on the pressure and temperature. The methanol formation is favored by increase in pressure.2.3. Reactor 2 (Dimethyl Ether (DME) Synthesis)After the crude methanol from reactor 1 is preheated, vaporized and then superheated between 300-320oC in a series of heat exchangers, it is then sent to the dimethyl ether (DME) reactor containing a dehydration catalyst (alumina) where methanol is partially dehydrated to an equilibrium mixture of DME, water and methanol which is a reversible and exothermic reaction.2CH3OH CH3OCH3 + H2O . (4)2.4. Reactor 3 (Gasoline Synthesis)In reactor 3, in presence of catalyst the product gas from reactor 2 converts to hydrocarbons including paraffins (alkanes), aromatics, naphthene (cycloalkanes) and olefins (alkenes), mostly from C6 to C10.2.5. Reactor 4 (Gasoline Treatment) To have high octane enumerate for synthetic gasoline and desirable volumetric properties, the product from reactor 3 is treated in reactor 4 to reduce the durene (tetra methylbenzene), Iso durene and tri methylbenzene components which have high freezing points.2.6. SeparatorFinally, in the reactor 4 two or three phase separation is done to obtain synthetic gasoline comprised of paraffins, aromatics and naphthene, non-condensed gas and water. The non-condensed gas is recycled back to the feed stream for reactor 1 and water is recycled back to the Steam Reformer (Syngas Generation Unit).3.0. Why STG+?The previous group answerable for GTL used the conventional GTL technology called Fisher Tropsh (FT) in their manakin process. Fischer-Tropsch (FT), which is a technology developed in early 1920s, converts gas into liquid hydrocarbons mainly diesel through a very complex process. While there have been significant improvements on the efficiency and technology of the Fisher-Tropsch process, the industry is in an urgent pauperization of new technologies capable of converting as much gas as pos sible into liquid fuels in a cheaper and more efficiently manner. As consequence, we decided to go for for our project the novel process called STG+ developed by Primus Energy. The main product of STG+ is gasoline as opposed to diesel. Since the most demanded liquid fuel in Canada, peculiarly in Alberta, is gas, we decided non use FT or any new technology producing diesel. STG+ has numerous advantages over the conventional GTL techniques such as bring low operating and peachy costs, higher production, better product quality and faster delivery times. The rival technology of STG+ is ExxonMobils MTG process. However, ExxonMobils MTG process has a greater environmental stupor and it is not very cost-effective. STG+ process was designed to correct some inefficiencies in the ExxonMobil process . The main correction is the integration of the reactors in a single-loop that increases the production and yields a higher quality of the gasoline with a less environmental impact A key exam ple is integration of the reactors in the STG+ process.4.0. Project Design/ salutary example4.1. Flowchart DescriptionThe lists of components that are considered in the simulation for the STG+ process and the yields in mass base for the one-quarter reactor (Keil, 2012) are shown in the Appendix (Table 1). The flow chart developed for the STG+ process is shown in the fig. 2 of Appendix.A brief explanation of the flowchart will be done now. First, our feedstock is basically the natural gas. For simplification purposes, our feed of natural gas is basically methane. Another feedstock that this process will have is fresh water. The water will be heated in a heat exchanger (HE-01) and will be mixed with the methane to enter the first reactor (R-01). In this reactor, carbon monoxide, carbon dioxide and hydrogen will be produced, as explained above. The fractional conversion in the first reaction is 83.4% of the methane, the limiting reactant. The conversion in the second reaction is 6% of the carbon monoxide (Choudhary et al, 1992). The exit stream of the reactor R-01 is cooled in a heat exchanger (HE-02), enters a compressor (CP-01) to increase the pressure for the second reaction process and, finally, enters another heat exchanger (HE-03) to adjust the temperature for the ideal temperature in reactor R-02. The operating conditions of this reactor are 69 bar and 380C (Wood et al, 2012). In it, basically, the syngas will be consumed to form methanol. The fractional conversion of this reaction is 63.7% of carbon monoxide (Lebarbier et al, 2012).The exit stream of reactor R-02 will pass through a heat exchanger (HE-04) to adjust the temperature of the mixture to enter reactor R-03. The methanol will form dimethyl ether (DME) and water. The operating conditions of this reactor are 12 bar and 325C (Wood et al, 2012). The fractional conversion of the methanol for this process is 76% (Kasaie et al, 2010).The stream that comes out of reactor R-03 passes through a heat ex changer (HE-05) to reduce its temperature and then enters a liquid-vapor flash vas (FV-01). The dimethyl ether along with the non-polar components will come out in the gas stream, while the water will come out in the substructure or liquid stream, which can be sent to the outflowing treatment plant. The gas stream will pass through a compressor (CP-02) and then through a heat exchanger (HE-06) to adjust the temperature and pressure for the fourth reaction process in reactor R-04. Basically, in this reactor, the dimethyl ether will be dehydrated in order to break down its molecule into -C2H4- radicals, which will be combined to form bigger molecules, as explained above. Since the reaction process is complex and the number of reactions is big, the stoichiometry of the process will be very complicated. at that placefore, this paper precisely shows the yield in mass basis of each component formed in reactor R-04 (yield per unit mass of total feed of components that are not listed a s inerts) (Aspentech Support Technology, 2001). Since only the dimethyl ether (DME) is a reactant in reactor R-04, all of the other compounds that enter reactor R-04 are considered inerts.The exit stream of reactor R-04 will pass through a compressor (CP-03) and through a heat exchanger (HE-07) to adjust the pressure and temperature for the last flash vessel (FV-02). This flash vessel is a liquid-liquid-vapor separator that will separate on the top the gas and lightest products. The middle liquid stream will be the gasoline formed (main stream) and the bottom liquid stream will be the water that was formed in the reactor R-04 and must be removed. The gas stream can be exchange to an industry that processes gas phase hydrocarbons, while the water removed can be sent to the effluent treatment plant.4.2. Thermodynamic Model and Simulation ConsiderationsThe simulation of the STG+ process was developed in the software Aspen Plus version 7.2. In our simulation, we chose the GRAYSON model , because it was developed for systems consisting of hydrocarbons, such as carbon dioxide and hydrogen sulfide. This method should return good results for temperatures in the range of 60F to 800F and pressures up to 3000 psia (Aspentech Support Technology, 2001). Since our process contains hydrogen and all the temperatures of the streams are within this temperature range, we can use the GRAYSON model (Aspentech Support Technology, 2001).The first three reactors (R-01, R-02 and R-03) were modeled in Aspen Plus as RSTOIC reactors since only fractional conversions and stoichiometry were considered for them. The last reactor (R-04) was modeled as an RYIELD reactor. In this model, the excitant data that is required consists of the outlet temperature and pressure of the reactor, as intimately as the yield values for the components that are products of the reaction process.4.3. Assumptions adopted in the simulation Natural gas feed consists only of methaneWe used only flash drums to perf orm the separation of the components after the reactions.The gasoline yields only consist of paraffins, olefins, aromatics and cyclic hydrocarbons from C2 to C11.Fractional conversions and stoichiometry are only considered for the first three reactors and no kinetic parameters for the reaction processes and catalyst deactivation are considered cod to lack of data.Even though the STG+ process is hearty known for the loop which defines the efficiency of the process, due to lack of data on fractional conversions for C2-C11 compounds, we restricted our simulation till gasoline production and planned to wander our product (Gasoline and Natural Gas) to the other parties who are in charge of any post treatment required.Since we are not including the durene/Isodurene in our output, the Gasoline treatment reactor is not considered.5.0. Economic EvaluationIn order to evaluate the economics of the project, a cash flow analysis is made based on the following considerationsOur business model consider buying treated natural gas to be used as both feedstock and fuel gas (we dont pay royalties because we are not producing it), paying for electrical energy consumption and revenues come from gasoline and natural gas sales.Two years for construction and 20 years of operations.340 days of production per year.Analysis in constant American dollars of January 2017, exchange rate of 1.30 CAD to USD.Annual non-fuel operating and maintenance cost equal to 3.6% (Haro P. et al ,2013) of total capital expenditures.Corporate income tax rate equal to 28%. electricity consumption, fuel gas required, flow rates (feed and products) from the simulation model.Current monetary values for gasoline, natural gas and electricity in Alberta, taken from Alberta Energy websites.Capital Cost Allowance (CCA) with a half year rule is considered for tax calculation purpose according to Alberta legislation. displace rate 10%.Capital expenditure (CAPEX) for syngas generation is estimated using figures for a known plant (Yang Ogden, 2005) and the following equation to take into account the different capacities. . (5)Where,Cx = capital cost for a plant of size x (Sx), Cb = capital cost of the known plant of size b (Sb).CAPEX related to the STG+ process itself is estimated based on the ratio given by Primus Green Energy (company proprietary of the STG+ technology) that syngas generation typically represents 60% of total capital cost for commercial-scale plant and the STG+ process itself represents the other 40%.Two scales are considered 10 MMSCFD of natural gas in the feed for comparison purpose with the previous years group and 62.5 MMSCFD of natural gas in the feed to evaluate the influence of the scale on the economic indicators.The economic indicators of the project are summarized in the following table commit Gas Flow rates (MMSCFD)1062.5Net Present Value NPV 10% (million $)14.66371.86Internal Rate of Return IRR12.12%22.87%Profit to Investment Ratio PIR0.140.97Breakeven price f or Gasoline (CAD/L)0.910.62Table 1 Economic Indicators for project evaluation (Detail calculation in Appendix)Finally, a sensitivity analysis is made to see the influence of different variables natural gas price, electricity price, gasoline price and capital cost on the NPV of the project. For these, all variables are changed +10% and -10% and the NPV are calculated. Results shown in the fig. 2 correspond to the case with 62.5 MMSCFD in the feed. However, it is the same trend in both casesFigure 2 Sensitivity Analysis for case 62.5 MMSCFDIt can be concluded that the project is economically feasible and the variable that impact the most the economics of the project is the gasoline price.6.0. RecommendationsWe recommend considering the fractional conversions for C2-C11 compounds in reactor 1 to have a better picture of STG+ with its close loop process.A thorough composition analysis for gasoline in the fourth reactor gives more realistic results.There is much scope to extend our work by adding gasoline treatment and distillation column (instead of flash drum for more efficient separation) with proper chemical reactions and stoichiometric fractional conversions and kinetics to improve the market value of our product.There is possibility for considering more components in the feed gas till C5-C6.In our model, due to lack of data, we focused on chemical reactions and stoichiometric fractional conversions. There is scope for more efficient designing by working on catalyst cycle life.7.0. ConclusionThe 21st century is witnessing the establishment of a new global business based on natural gas processing. As a consequence, the gas-to-liquids (GTL) industry is becoming increasingly important as it is getting more difficult to find and extract new oil reserves as well as the presence of more environmental restraints. This is why we decided to apply the new STG+ process technology in our project to demonstrate its efficiency in the conversion of methane to gasoline. As pr eviously stated, we decided to differ from the previous group process, mainly because its technology is old and their product is diesel as opposed to STG+ process which is a novel technology and its product being gasoline, which is more demanded in Canada. We chose to do the simulation of a small scale GTL plant that processes 10 MMSCFD of methane, producing 672 bbld, which resulted in an economically viable process. The economic indicators showed that, by increasing the production of gasoline, the profit would increase significantly (proven with the case 0f 62.5 MMSCFD). In conclusion, STG+ might be indeed prospered and profitable in Alberta if there is a reliable source of natural gas and good market conditions. 8.0. ReferencesAlberta energy website.http//www.energy.alberta.ca/NaturalGas/1316.asp. Accessed on March 16th, 2017.Alberta energy website.http//www.energy.alberta.ca/Electricity/679.asp. Accessed on March 16th, 2017.Aspentech Support Technology, Inc. Aspen Physical Prope rty System 11.1 Cambridge, MA, September 2001.Choudhary V. R., Rajput A. M., Prabhakar B Low temperature oxidative conversion of methane to syngas over NiO-CaO catalyst Chemical engineering Division National Chemical Laboratory, India, May 1992.Haro P, Trippe F, Stahl R, Henrich E. Bio-syngas to gasoline and olefins via DME A comprehensive Techno-economic assessment Apple Energy 2013 volume 108 page no. 54-65.Heng H.C., Idrus. S The proximo of gas to liquids as a gas monetization option diary of Natural Gas Chemistry 13, 2004 pages 63-70.http//www.albertagasprices.com/index.aspx?fuel=C . Accessed on March 16th, 2017.Kasaie M., Sohrabi M. energizing Study on Methanol Dehydration to Dimethyl Ether Applying Clinoptilolite Zeolite as the Reaction Catalyst Chemical Engineering Department, Amirkabir University of Technology, Tehran, Iran, January 2010.Keil, Frerich J. Methanol-to-hydrocarbons process technology Department of Chemical Engineering, practiced University of Hamburg-Harburg , Hamburg, Germany, July 1998 page 49.Larminie, James, Dicks, Andrew Fuel Cell Systems Explained West Sussex, U.K. John Wiley Sons 2000.Lebarbier V. M., Dagle R. A., Kovarik L., Adarme J. A. L., King D. L., Palo D. R. Synthesis of methanol and dimethyl ether from syngas over Pd/ZnO/Al2O3 catalysts Richland, USA, June 2012.Mbodji M., Commenge J.M., Falk L., Di Marco, Rossignol F., Prost L., Valentin S., Joly R., Del-Gallo P. Steam methane reforming reaction process intensification by using a milli structured reactor Experimental setup and model validation for global kinetic reaction rate estimation, Chemical Engineering Journal, vol. 207-208, pages 871-884.Primus Green Energy website (http//primusge.wpengine.com/press-room/white-papers/), Accessed in March 2017.Shell Global Website (http//www.shell.com/energy-and-innovation/natural-gas/gas-to-liquids.htm), Accessed March 05, 2017.Wood, David A., Nwaoha C., Towler, Brian F Gas-to-liquids (GTL) A review of an industry offering several routes for monetizing natural gas Journal of Natural Gas Science and Engineering, Volume 9, November 2012.Yang, Christopher Ogden, Joan M. (2005).Analyzing Natural Gas Based Hydrogen Infrastructure Optimizing Transitions from Distributed to Centralized H2 Production Institute of Transportation Studies UC Davis.9.0. Appendix portion in Aspen PlusComponent nameFormulaMass yieldMETHANEMethaneCH4-METHANOLMethanolCH4O-COCarbon monoxideCO-CO2Carbon dioxideCO2-H2OWaterH2O-ETHERDimethyl etherC2H6O-H2HydrogenH2-OCTANEn-OctaneC8H183.582HEXANEn-HexaneC6H142.702HEPTANEn-HeptaneC7H163.142NONANEn-NonaneC9H204.022DECANEn-DecaneC10H224.462N-C11n-UndecaneC11H2424.602N-C5n-PentaneC5H1236.078OXYGENOxygenO247.549ETHANEEthaneC2H64.901PROPANEPropaneC3H845.691N-BUTANEn-ButaneC4H1069.321ISOC4IsobutaneC4H10101.615ISOC52-Methyl-butaneC5H1275.269ISOC62-Methyl-pentaneC6H1434.921ISOC72,2-DimethylpentaneC7H163.137ISOC82,2-DimethylhexaneC8H181.690ISOC92-MethyloctaneC9H200.491ISOC102-MethylnonaneC10H2237.092ARO MC6BenzeneC6H64.024AROMC7o-XyleneC8H1

Triple Vessel Ischemic Heart Disease Treatment Case Nursing Essay

Triple Vessel Ischemic Heart Disease word Case Nursing EssayMr. MS is a 58-year-old Malay male who was previously diagnosed with hypertension, gout and triple vessel ischaemic heart unhealthiness. He offset presented with bureau painfulness in March 2010 where he was diagnosed with ischaemic heart dis order. 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 collectible 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, unremarkably relieved by sublingual GTN and was currently admitted for the 4th time for chest pain not relieved by GTN. ECG done 2 hours after aggression of chest pain showed ST economic crisis of 2mm at leads I, aVL, V3 V6 and left axis loss with no Q waves. Trop T was positive (2 .75 ng/ml) at 4 hours after onset and other cardiac enzymes were also raised signifi ejecttly. 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 medicament regime of simvastatin, metoprolol, cardiprin, ISDN, amlodipine and GTN. interest admission, he was well in the ward with no recurrence of chest pain and did not pose any new complaints. He was dis forethoughtd 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.2) clinical HISTORYChief ComplaintChest pain for 1 day. account statement of Present IllnessMr. 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 fast onset. He described the character of the pain as crushing in nature and radiated to his tell apart. This episode of chest pain was the most severe since he was set-back 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 yield of. His discomfort was made worst by exertion so he lay in bed to recover. Despite this, he had other 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 tierce times per week, especially on exertion such as when strain ing while passing motion. During these attacks, he uses sublingual GTN to relieve his symptoms and normally feels much break down after that. He only comes to the hospital when GTN does not work to relieve his symptoms.Systemic ReviewMr. 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. intestine and urinary habits ar normal. His sleep has not been affected until this current episode whereby he was awoken by the chest pain.Past Medical HistoryMr. MS was diagnosed with hypertension 6 long time ago when he had an episode of headache. He has been on medical specialty 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 g out. 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 line of work 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 building block 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 termination through with the procedure. Following thi s 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 contraceptive pill Simvastatin 20mg ODTab Metoprolol 75mg BDTab Cardiprin 100mg ODTab Isosorbide Dinitrate (ISDN) 5mg TDSTab Amlodipine 10mg ODSublingual Glyceryl Trinitrate (GTN) PRNHe is compliant to his medication regime.Mr. MS is not known to have diabetes or hyper lipoidemia. He also does not have any known food or drug allergies.Family HistoryMr. 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 argon healthy. None of them have hypertension, diabetes, ischemic heart disease or malignancy.Social HistoryHe 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 tha t 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. in that respect were no tendon xanthomata, xanthelasma, pallor, corneal arcus or pedal edema. His JVP was not raised. His clinical parameters areBlood Pressure 158/94 mmHgHeart Rate 94 beats per minute. Regular rhythmRespiratory Rate 20 breaths per minuteTemperature 37CSpO2 97% under room airOn scrutiny 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 in that location 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 amplification was equal on both sides. P ercussion and tactile vocal fremitus was normal and equal on both sides. On auscultation, vesicular breath sounds were heard end-to-end 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 REASONINGProvisional diagnosingAcute myocardial infarction with underlying triple vessel ischemic heart disease and hypertensionWith 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 crisp coronary particular 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 collect 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 complications of acute myocardial infarction but these developments should be watched out for throughout his admission as complications may arise later.Differential DiagnosisPulmonary embolismPulmonary 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 try 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 peg down becomes worse or complications develop.Aortic dissectionAortic 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 pretermit of profuse sweating, signs of heart pump dysfunction and a normal ECG. Risk factors are usually un controlled 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 grade THE PROBLEMS1. Acute chest painMr. 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 some(prenominal) angina attacks since his initial diagnosis, it is highly likely that he is having an acute myocardial infarction. Without further a due, he take an electrocardiogram (ECG) and cardiac enzymes tested to distinguish between the different acute coron ary syndromes so that the appropriate treatment protocols may be initiated for him as before long 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 CABGMr. 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 fe at 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 medicationMr. MS is on several medications for his triple vessel ischemic heart disease and will require revascularization surgery soon in order to ebb 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 th e 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 at once if GTN fails to relieve his symptoms.4. Regular screening for comorbid diseasesMr. 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 film to maintain a healthy lifestyle of a g ood, 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 RESULTS1. Electrocardiogram (ECG)To tang 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 EnzymesTo behavior 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 Abortion Debate in the 2004 Presidential Election :: Politics Political Essays

The Abortion Debate in the 2004 Presidential ElectionAbortion is a major issue that affects individual lives daily. It has puzzle a debatable factor in determining the solution in having the free choice for a woman to end their unborn baby. Even though it was not fully recognized in the presidential election, there was discussion as to whether or not it is morally right to perform this practice. President bush-league believes that aborting an unborn baby is morally wrong because he believes in protecting the rights of the unborn and believes that partial birth abortion is a vicious act that discriminates against children who be inches away from life. On the opposing side is Senator Kerry, who believes that aborting an unborn child should be permitted because he believes in protecting womens choices and enforcing womens privacy rights. President bush believes banning abortion except for the cases in rape, incest, or to save the mothers life. He believes in the rights of the unborn and born baby. In 2003, President Bush signed the partial tone Birth Abortion Ban Act of 2003, which prohibits the practice that performs the overt act, other than completion of delivery that kills the partially delivered living fetus. (http//www.theorator.com/ accountings108/hr1545.html). By President Bush write this act he explained that there would be the termination of this terrible act in killing innocent lives that are about to come in the world. The bill I am about to sign protecting innocent new life from this practice reflects the compassion and humanity of America. (http//www.whitehouse.gov/news/releases/2003/11/20031105-1.html). His main close is to reduce the numbers of abortions in America. (http//www.issues2000.org/George_W__Bush_Abortion.htm). Senator Kerry believes that it is not the issue of pro-abortion but the issue of pro-choice. He believes that every woman should have the right of choice, which is taken away from her resulting in banning abortion. My persona l belief about what happens in the fertilization process is a human being is first formed and created, and thats when life begins (http//www.sonrisecma.com/blogs/sonrise3/archive/2004/07/22/611.aspx). He believes that the government should not have a right to intervene in somebody else judgment and quotes on Bill Clinton statement that Abortion should be rare, but it should be safe and legal and the government should stay out of the bedroom.(http//www.npr.org/politics/issues2004/) He believes that enforcing womens privacy rights would let the mother decide to abort her unborn baby or not.Liberal is pro-abortion and Conservation is anti-abortion. In both opposing sides, there are alternatives that relates to abortion.

Choctaw indians :: essays research papers

The Choctaw IndiansThe Choctaw Indians is a tribe of Musksgean stock .The Choctaws were once part of a larger tribe that included the Greeks and Seminoles and are considered ace of the five civilized tribes (Cherokees , Greeks, Choctaws , Seminoles, and Chickasaws) . At one time Choctaw territory extended from Mississippi to Georgia, but by the time Europeans began to arrive in North the States they were primarily in Mississippi and Louisiana.The Choctaw Indians were into cultivation , they hunted and raised corn along with a host of other crops. One of their chief religious ceremonies was a harvest celebration cal take , The green corn dance. According to one legend, the Choctaw were created at a sacred mound called Nanih Waiya, near Noxapater ,Mississippi.In 1540, the Spanish explorer Hernando De Soto led the first European expedition through Choctaw territory. Fighting broke out after the Choctaw refused to supply the Spaniards with a guide and transportation. The Spaniards were in the wrong because the Choctaw Indians were friendly especially with the French and allied with them during the intercolonial wars between France and England . Some Choctaws fought with Jackson at New Orleans against the British. In 1830, the United States Government passed the Indian removal Act. This act called for easterly Indians to be moved West to make room for white settlers. The Government then forced the Choctaw to sign the Treaty of Dancing Rabbit Creek.The Treaty interchange the Tribes Eastern land for an area in the Indian territory, in what is now Oklahoma.

Henry Moore Essay -- essays research papers fc

Many sculptors have come and gone over the years, expiration light traces or none at alone of their presence in the sculpture realm. Henry Moore does non fit into either of these two categories. Because of his original dah and techniques, Henry Moore has made a dramatic effect in present day sculpting. He has opened many doors for practicing artists in a sense that was not portrayed prior to his era. Henry Moore combined his childhood experiences with his interactions between other artists to develop his distinguishing style of sculpting.Henry Moore was born in Castleford, Yorkshire on July 30,1898. He was the 7th of eight children to Raymond and Mary Moore. His father, Raymond Moore, worked at a local mining ore while his mother stayed at home tending Henry and his siblings. Henry first unquestionable an interest for art while attending Sunday school. He specifically remembered a talk on Michelangelo, which initiated his interest in sculpting. Henrys teachers all through seco ndary school encouraged his interest in the art field.When Henry Moore graduated from school, he was not too sure what he wanted to do with his life. His father preferred him to become a teacher, a social advance for children in mining villages. Moore pondered the thought of becoming a teacher and ultimately fell into the field after there was a teacher shortage in 1914 due to people being called up for selected services. Moore spent three misfortunate years as a teacher before he was called up to Civil Services Rifles. The Civil Service Rifles was much more enjoyable for Moore and he would later write to his father about his pleasurable experiences.While fighting battles in France, Moore was injured and sent back to England to be hospitalized. Following the war, Moore was given a grant to further his education at Leeds School of Art. Moore received a scholarship to transfer from Leeds to Royal College of Art (RCA) in London, a more honored art institute. After Henry Moores gradu ation from RCA in 1924, he traveled to Italy to study a different cultures artwork. His exposure to Italian artwork provided Moore with different views on the meaning of art. In 1926, Moore returned to RCA and took up teachin... ...culpture, Moore reenacts the moments right before death. This type of situation is probably something Moore can relate to because of his experiences in WWI. Henry Moore left an everlasting impact on the world of art. The way he conveyed his emotions and feelings into his subject matter is inspirational to all who view his work. Moore introduced a newly-sprung(prenominal) style of sculpting that defined the use of shape and rhythm. Moores artwork while be a model for future aspiring artists who want to explore new forms of sculpting.BibliographyAndrews, Julian. Henry Moore Sculpting the 20th Century. Dallas Yale University Press, 2001. Moore, Henry. Henry Moore My Ideas, Inspirations, and Life as an Artist. New York Collins and Brown. 1999.Green, Perry. Henry Moore Biography. 2001. 19 October 2002. .Wallis, Anthony. Henry Moore. 2001. 15 October 2002. http//www.casandpont.freeserve.co.uk/moore.htm.

war on cocaine :: essays research papers

The potential supply of medicines is virtually unlimited trafficking routes and points of entry into the U.S. be multitudinous and once destroyed laboratories, drug shipments, planes, money, chemicals, and separate trafficking assets can be replaced easily. Robert L. Clawson and Rensselaer W. Lee give their readers insight into cocaine trafficking, the effects of cocaine on the Andes, and what has been done to lower the amount of cocaine produced and exported. Together the authors winder a picture that the cocaine trade is here to stay and that it has not fundamentally changed since the 1980s. They are realists about the severe limitations on any element of U.S. and transnational strategy to control supplies of coca and cocaine in countries such as Colombia, Bolivia, and Peru. Clawson and Lee state, Our suspicion is that the most effective counter narcotics program for the Andean nations depart be ones that are designed by and utilize by governments concerned, rather than by the United States or International Aid Agencies. When the counter narcotics efforts were initially implemented they sometimes seemed successful, but the drug traffickers quickly learned how to beat the system. International counter narcotics efforts in the 1980s and 1990s have been unsuccessful in eliminating the drug cartels by extraditing, eradicating coca, or having a strong, counter trafficking effect on the supply of drugs in the Andean countries. These counter narcotics efforts are the best examples of the poor performance train of International cocaine control.One of the counter narcotic efforts was to eliminate the drug cartels, which were revolutionizing the production and transport of multiton loads of cocaine to foreign markets. The Medellin cartel and the Cali cartel are often remembered as two of the more dominant drug trafficking organizations in the 1980s and 1990s. The Medellin Cartel is considered to be the more violent drug organization. Followed by the little vi olent organization, known as the Cali cartel, which took over the cocaine trade after the Medellin cartel fell apart. Pablo Escobar was the original pioneer of the Medellin Cartel. He also was the leader of it from the mid(prenominal) eighties all the way till his assassination by the Medellin Search Bloc in December of 1993. Pablo Escobar and other members of the Medellin cartel successfully accomplished their governmental objective, which was to defeat the U.S.-Colombian extradition treaty and dominate the Colombian justice system. The U.S. extradition treaty was important in that it allowed for Colombia to send traffickers to the United States for trial and sentencing.

Using Nazi Tactics Against Smokers Essay -- Argumentative Persuasive A

Using Nazi Tactics Against SmokersPrior to the 1930s, Germany was Europes most hospitable country for Jews. While Jews were only one share of the population, they were poop of Germanys law and medical students. In some German cities, Jews were the majority of doctors. While Jews were only five percent of the Berlin population in 1905, they paid 31 percent of all income taxes collected. For Germany as a whole, Jewish income was more than three times the national average. In his book, Migration and Cultures, Dr. Thomas Sowell adds that Jews were so highly integrated into German economical and social life that in nearly half of all Jewish marriages during the 1920s one of the spouses was Gentile. During World War I, Jewish-American publications were investigated and prosecuted by the U.S. Government for writing favourably about Germany, a nation at war with the U.S. Much of German history has been one of racial toleration. This is partially seen by their anti-slavery positions in Br azil and the unite States. In the United States, Germans had a large hand in assisting runaway slaves by way of the underground railroad. Germans also had an established reputation of getting on very well with American Indians.So why the story about pre-Nazi Germany? I think examining it raises an interesting question that few bother to answer namely, if Germany was so hospitable to Jews, relative to other countries, how in the world did the Holocaust happen? There are several alternative explanations such as Hitlers massive integrating of government power. Then theres the fact that German culture places high values on regimentation and obedience to authority. An important part of the answer of how Germans came to accept Jew... ... no more. The nations tyrants prepare now turned their attention to the vilification of libertine food shackles such as McDonalds, Burger King, Wendys and Kentucky Fried Chicken, charging them with having created an addiction to fatty foods. Thus, t he tyrants claim, fast food chains feed contributed to obesity-related problems and growing healthcare costs. Like the anti-tobacco zealots they call for regulation, compensation for injury and taxes on foods they deem to be non-nutritious. In addition to fast food chains, these tyrants have targeted soft drink and candy manufacturers. Chinese and Mexican restaurants are also in their sights because they have meal servings deemed to be too large. In their campaign against fast food chains, restaurants and soda and candy manufacturers the nations food Nazis always refer to the anti-tobacco campaign as the model for their agenda.