Skulls identification Essay Example | Topics and Well Written Essays - 500 words

Skulls recognizable proof - Essay Example It likewise has bigger teeth than those of current people and the jaw additionally comes up short on the anticipating hard jaw that is found in Homo sapiens. They had enormous supraorbital tallness since they had huge circles which propose they had huge eyes and visual cortices. Nuchal region tallness is little and this is because of the high condylar position. Condylar position is very high and the explanation concerning why there is lopsidedness of the head. The ordered status of the Mystery skull # 2 is Homo erectus. This is so in light of the fact that the skull has a huge face with low, slanting temple and an enormous forehead edge. It additionally has a wide and level nose. The skull is additionally wide and long with sharp points at the back dissimilar to the bend found in current people. The bones of the skull are extremely thick and framed a little focal edge, additionally called midline bottom, along the highest point of the skull. The jaws are huge and thick without pointed jaw. The molar teeth have huge roots which are diminishing towards a cutting edge size. Other than the referenced, the puzzle skull #2 has an adjusted skull, a more extreme face, and littler teeth that legitimize that it coordinates those of Homo erectus. In Homo erectus, the supraorbital tallness was developed however littler than that of recently discovered skull which arraigned they had little eyes. They have a very much evolved opened masticatory mechanic al assembly which plainly characterize the nuchal region tallness. Despite the fact that it had very much evolved nuchal musculature, the parity of the head was still less immaculate that it is today on current people. Condylar position is higher contrasted with that of Australopithecus aficanus in light of the fact that it has all around created nuchal territory that can adjust the head. The ordered status of the Newly Found skull is Australopithecus aficanus. This is so on the grounds that the jaws and teeth are halfway those of people. The incisor and canine teeth are shorter and littler. The hole (diastema) in the midst of the canines and next teeth additionally shows that the Newly Found skull matches Australopithecus

Protein Article Research Free Essays

Mysterious Dr. Louis Cohen SCI/241 Protein Article Research January 3, 2012 According to Centers for Disease Control and Prevention, protein is found in each cell in the body. Protein gives our bodies vitality that is fit to be utilized. We will compose a custom paper test on Protein Article Research or on the other hand any comparable subject just for you Request Now After it is processed, it becomes amino acids. There are 23 amino acids which are basic to the body and are required for the body to work appropriately. Amino acids are required so as to fabricate muscle quality. Protein can be found in creature nourishments, and it can likewise be found in plant food sources. Creature nourishments, for example, meats, cheeses, and dairy items are finished wellsprings of protein, while plant sources are a fragmented protein source since they are low in any event one of the basic amino acids. Plant sources should be overwhelmed by an integral protein source so as to be sure that protein needs are being met. For instance, in the event that you eat chicken, that would be a finished wellspring of protein, though on the off chance that you eat rice for a supper, you should add beans to make the protein utilization complete. A couple of instances of plant sources or a deficient protein source is as per the following: corn, tofu, grains, a few vegetables and organic products. Since I am a multi year elderly person, I need 46 grams of protein daily. I can without much of a stretch meet and surpass the sum that is vital by eating the entirety of my suppers in a day and by devouring all other fundamental supplements. In spite of the fact that getting the perfect measure of protein is sound for the body, getting an excessive amount of can be unsafe. At the point when individuals expend a lot of protein, they increment their danger of weight gain. Additionally, high protein diets can put a strain on the kidneys since they free the protein from the blood, may add to malignant growth since it increment blood levels of IGF-1, and may cause dietary lacks. Similarly as high protein diets can cause clinical ailments, low protein diets can do likewise. An eating regimen with an absence of protein can cause skin pigmentation, looseness of the bowels, swollen paunches, rashes, and change in surface or shade of the hair. Protein is on the body’s basic needs, nonetheless, to an extreme or excessively little of any supplement that is fundamental can hurt the body. It is crucial that individuals get familiar with the measures of supplements their body requires so as to become or stay sound. Step by step instructions to refer to Protein Article Research, Essays Protein Article Research Free Essays Protein Article Research Sara Langrell December 15, 2011 Nutrition SCI/241 Dr. Venessa Lee Abstract: Athletes have been scanning for a considerable length of time for an approach to lessen the measure of recuperation time between exercises. In view of this issue there has been a considerable amount of research directed to discover what should be possible, on the off chance that anything, to either lessen or wipe out recuperation time. We will compose a custom article test on Protein Article Research or on the other hand any comparative subject just for you Request Now One of the speculations is to build protein admission over the day by day suggested sum, in this manner furnishing the body with extra amino acids that advance recuperation. In spite of the fact that this appears the ideal arrangement, there are a few blemishes. No doubt in addition to the fact that you need extra proteins an extra wellspring of fuel to permit the proteins to carry out their responsibility, in this way with everything taken into account a parity must be struck. The recuperation time required from an exceptional work out is an immediate aftereffect of the stretching, or even once in a while, tearing of muscles. On the off chance that the work out is too extreme muscles can really be harmed. The harm can be grouped into three distinct classifications: Type I, Type II and Type III. Type I muscle harm is delegated the irritation that happens 24-48 hours after not used to work out. Type II is named an intense debilitating agony either from the total tearing of the muscle and facia or the interruption of a couple of filaments with the facia staying flawless. 1 Type III is named a spasm or irritation that happens either during or straightforwardly following an exercise. 1 Because of these issues, numerous long stretches of research have been led to attempt to decide whether there is whatever should be possible to slow or even dispose of the harm never really muscle during exercise. At the point when muscles are extended or harmed proteins are both separated and blended all simultaneously. The breakdown isn't all awful for the body, as it controls conceivably harming and broken proteins. 2 In direct reaction to the breakdown, the blend that happens would appear to be useful for the body; anyway it can cause an unevenness in muscle proteins. 1 Based on investigate it has been resolved that supplanting amino acids during and after exercise assists with adjusting the protein insufficiency and aid the fix procedure. A significant number of the prescribed approaches to do this is to expand protein allow or potentially decide on an amino corrosive substitution supplement. Subordinate upon the sort of activity you are inclined to will decide the kind of supplement that would be suggested. Checking with a doctor would be the best wagered before starting any kind of treatment. Book reference: 1. ) Nosaka, Kazunori PhD, Muscle harm and amino corrosive supplementation: Does it help recuperation from muscle harm? Worldwide SportMed Journal, Vo. 8 No. 2, 2007, pp. 54-67 2. ) Phillips SM, Protein necessity and supplementation in quality games. Nourishment, Vol. 20, 2004, pp. 689-695. The most effective method to refer to Protein Article Research, Papers

William Goldings Lord of the Flies Essay -- Essays Papers

Ruler of the Flies I decided to do one of my book writes about William Golding’s Lord of the Flies. The explanation I picked this book is on the grounds that it manages numerous issues that are imperative to driving a strong Christian based life. It likewise manages a few issues that were discussed in class, for instance segregation, supplication and acculturated conduct. The book begins with Ralph and Piggy strolling through the forested areas on what gives off an impression of being a remote location. We are informed that a plane shipping numerous little fellows between the ages of 5 and 12 slammed on this island and these are the initial two characters that we meet. Ralph and Piggy discover out of the forested areas and onto a sea shore where they find a conch shell that can be played as a horn. Ralph sounds this horn and not long after various little youngsters rose up out of the forested areas. It is currently uncovered that no grown-ups are on the island and it is only the young men. They at that point choose to frame a make move government and piggy delegates Ralph to be the pioneer since he started the gathering. One kid named Jack, an individual from a boy’s ensemble, fights the way that Ralph was named the pioneer. So to please Jack, Ralph reveals to him that he will be accountable for chasing and assembling food, this alongside prodding Piggy about his weight satisfies Jack. The young men them split up and start to investigate the island and Jack arranges the principal chase, which is fruitless. Over the long haul Ralph sees that huge numbers of the young men aren’t truly accomplishing any work and would prefer to play or resting rather, this concerns him a bit. He at that point goes out to investigate the island with a choirboy named Simon, when they returned they assembled a conference by flagging the conch. At this gathering Ralph sets up some essential standards. The primary ones being that you can possibly talk at a gathering on the off chance that you are holding the conch and that a fire must be prop up constantly on the mountain in the event that a boat passed by with the goal that they could be safeguarded. Different young men like the thoughts and surge up the mountain to light a fire. After they assemble a lot of kindling they understand that no one can light a fire without matches. Piggy at that point recommends that they utilize the f ocal points of his glasses to start a fire. The fire begins and gets somewhat wild and Piggy imagines that one of the more youthful young men has been singed to death. The entirety of different young men snicker at Piggy and deny the occurrence. This is the first ... ...ll right. So we perceive how significant guardians are and the amount they can impact their kids. These young men were too youthful to ever be abandoned alone and they couldn’t recognize good and bad. I’m sure that as grown-ups they would think back and perceive how antagonistic and abhorrent they had become. Somebody who has a comparable perspective on this book is Kristian Moe who is an instructor in New York. I discovered this announcement at www.malvik.no/engelsk/lordoftheflies.htm, he composes, â€Å"I feel that the book is exceptionally miserable. Here and there it is even somewhat unusual. It depicts human instinct in its most noticeably awful and darkest. It is frightening, and it makes me consider the universal wars, and about Hitler’s bigotry and contempt. I can not accept that we have such huge numbers of dim sides inside us, yet perhaps we do.† All in all, I need to state that I appreciate this book since it is energizing and frightening simultaneously. I’m sure that everybody at one point in their life has longed for being on a remote location, however I’m likewise sure that no one would need their experience to resemble the one we find in this book. Except if obviously that have no feeling of Christian qualities and are eager to expose themselves to that sort of insidious conduct.

Patient information and presenting complaints - Free Essay Example

1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests show ed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: Drug route Dose frequency Start date Stop date Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Day 1 Diabetes mellitus T.Rosiglitazone 4mg od Day 1 Diabetes mellitus T.Rosuvastatin 20mg nocte Day 1 Dyslipidaemia T.Fenofibrate 160mg od Day 1 Dyslipidaemia T.Ezetimibe 10mg od Day 1 Dyslipidaemia T.Lovastatin 20mg nocte Day 1 Dyslipidaemia T.Ticlopidine HCL 250mg od Day 1 Prophylaxis against ischaemic T.Losartan 50mg od Day 1 CHF T.Famotidine 20mg od Day 1 Prevent GI upset Neb ipratroupium bromide 500 µg, salbutamol 5mg, normal saline 2:1:2 qqh Day 1 Day 3 AEBA IV Hydrocortisone 100mg stat Day 1 Day 1 AEBA Neb Salbutamol 1 puff prn Day 1 AEBA/chronic asthma MDI Budesonide 200mcg 2 puffs bd Day 1 AEBA/chronic asthma T. Azitromycin 500mg od Day 1 Day 3 Pneumonia IV Ceftriaxone 2g stat Day 1 Day 1 Pneumonia IV Furosemide 40mg bd Day 1 Day 2 CHF S/C Actrapid 5? , 10? Day 1 Day 2 Diabetes mellitus T. Prednisolone 30mg od Day 2 AEBA MDI Beclomethasone 200mcg 2puffs tds Day 2 Chronic asthma T.Cefuroxime 250mg bd Day 2 Pneumonia T. Furosemide 40mg od Day 2 CHF S/C Mixtard 30/10? Day 3 Diabetes mellitus 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique sin ce day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple the rapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and 9mmol/L post-meal provided there is no significant hypoglycaemia, and HbA1c of ?7% is a more practical target compared to HbA1c of 6.5%.1,4 SAR was started on insulin injections to lower and control her blood glucose level during hospital admission. Type 2 diabetes mellitus management guideline recommends the addition of insulin to the two oral hypoglycaemic agents after the dual oral therapy fails.4 However, rosiglitazone is contraindicated in patient with CHF and not recommended in patient with history of IHD; therefore the use of rosiglitazone should be reviewed.1,5-6 The most appropriate action is to withdraw rosiglitazone from the drug regimen and close monitoring of patients random blood glucose and glycosylated haemoglobin (HbA1c) should be carried out to confirm the eff ectiveness of the combination therapy (gliclazide and insulin) in controlling the blood glucose level. Although metformin is the first line treatment of Type 2 diabetes mellitus, it is contraindicated in Type 2 diabetic patients undergoing treatment with CHF and there is increased risk of lactic acidosis in severe renal impairment patient, therefore addition of metformin should be avoided in this case.1,4 During the hospital admission, SAR was educated on the proper technique of insulin injection. In this case, the decreased plasma levels of haemoglobin and red blood cells in the heart failure patient were most likely exacerbated by the administration of rosiglitazone.1 If the anaemia problem is not improved upon the withdrawal of rosiglitazone, erythropoietin and iron therapy can be considered.9 On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 Sh e was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and c ontrol of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs a nd avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic counselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthma tic patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ?2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ?2 agonists act on ?2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ?2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ?2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-?) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ?2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ?2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ?2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of i pratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-bli nd randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p0.0001).25 Chung et al. (2009) reported that addition of LABA may potentiate the anti-inflammatory properties of ICS as addition of formoterol to budesonide resulted in 63% reduction in severe exacerbation rates.26 Other findings of the study are local and systemic side effects of ICS become more frequent when used alone at doses above 800mcg/day, and the increased efficacy of combination with formoterol was achieved with lower dose of budesonide than was requi red in the budesonide group..26 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ?40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan-treated group showed a lower discontinuation rate due to side effects (9 ·7 vs 14 ·7%, p 0.001), including cough (0.3 vs 2.7%). These results suggested that losartan has similar benefit in improving survival in CHF as enalapril and is significantly better tolerated.31 A randomised trial involved 5010 patients with NYHA class II, III, or IV demonstrated that valsartan significantly reduced the combined end point of mortality and morbidity by 13.2% (P=0.009) and lowered the incidence of hospitalisation (13.8% vs 18.2%, P0.001)) compared to placebo. Significant improvements in signs and symptoms, NYHA class, ejection fraction and qualit y of life were also observed in valsartan-treated group (P0.01).32 3.4 Type II diabetes mellitus 3.4.1 Evidence for continuing sulphoynylureas when initiating insulin therapy in Type II diabetes mellitus A multicenter and randomized controlled trial demonstrated that combination therapy resulted in significantly lower HbA1c levels (p0.001) as compared to insulin monotherapy. There were no significant difference in the hypoglycaemic event rate between the insulin combination and monotherapy (0.36 vs 0.48).33 Kabadi et al. (2003) supported the efficacies of various sulphonylureas in achieving desirable glycaemic control in combination with insulin. Weight gain, number of hypoglycaemic events and daily insulin requirement were significantly lowered (p0.01) for patients treated with both sulphonylureas and insulin as compared to insulin-treated group.34 3.4.2 Evidence against the use of rosiglitazone in diabetic patients with CHF Thiazolinediones are associated with risks of weight gain, fluid retention, peripheral oedema and plasma volume expansion (lead to increased risk of anemia and new or worsening CHF).35-37 A double-blind randomised trial demonstrated that rosiglitazone significantly increased incidence of oedema (25.5% vs 8.8% placebo,P=0.005) and use of CHF medication (32.7% vs 17.5% placebo, P=0.037) in Type II diabetic patients with CHF. 38 Cobitz et al. (2008) evaluated the potential associations of CHF and myocardial ischaemia events in Type II diabetic patients enrolled in clinical trials with rosiglitazones. Higher odds ratio for CHF incidence was obtained when rosiglitazone is combined with insulin or sulphonylurea: rosiglitazone monotherapy versus placebo (OR 0.25), sulfonylurea plus rosiglitazone versus sulfonylurea monotherapy (OR 0.95) insulin plus rosiglitazone versus insulin monotherapy (OR 1.63).39 More myocardial ischemia incidences were reported with rosiglitazone (2.00%) versus con trol (1.53%).39 Nissen et al. (2007) also reported a significant increased risk of myocardiac infarction (OR 1.43, P=0.03) and a borderline significance of increased mortality from cardiovascular causes (OR 1.64, P=0.06) in the rositaglizone group compared to control group.40 The European Medicines Agency (EMEA) and Medicines and Healthcare products Regulatory Agency (MHRA) have issued advice that the use of rosiglitazone in patients with IHD or peripheral arterial disease is not recommended and it is contraindicated in patient with CHF and acute coronary syndrome.4,41 3.4.3 Evidence for combination therapy of statin and ezetimibe or fibrate in treating complication of diabetes mellitus Patients with Type II diabetes mellitus commonly have raised plasma concentrations of low-density lipoprotein cholesterol (LDL-C) or triglycerides, or low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) associated with higher cardiovascular risks. A multicenter, double-blind randomised trial consisting of 1229 Type II diabetic patients demonstrated the efficacy and safety of combination treatment of ezetimibe and simvastatin in providing additional lipid-modifying benefits compared to atorvastatin monotherapy.42 Ezetimibe/simvastatin group showed a significant greater reduction in LDL-C (-53.6% vs -38.3%), superiority in attaining LDL-C levels 70mg/dL (p0.001) and significantly better improvement for total cholesterol, HDL-C and non HDL-C (p?0.001) compared with atovarstatin group. Incidence of clinical adverse effects such as gastrointestinal and hepatocellular-related rashes or allergic reactions and laboratory adverse effects including elevation of creatine kinase and hepatic transaminases were similar in both treatment arms.42 In the simvastatin plus fenofibrate for combined hyperlipidaemia (SAFARI) trial, greater significant changes in triglycerides (-43.0% vs -20.1% with simvastatin alone), LDL-C (-31.2 vs -25.8%) and HDL-C (+18.6% vs +9.7%) were observed in Type II diabetic patients with mixed dyslipidaemia receiving fenofibrate and simvastatin (160/20mg daily) treatment. No drug-related clinical myopathy and liver function severe abnormalities were reported over a 18-week study period.43 The main concern associated with the combination therapy of statin and fibrates is the potential risk of myopathy and rhabdomyolysis, and the interaction is substantial with gemfibrozil.44-45 To date, there is inadequate evidence to conclude that combination treatment of fenofibrate and statin increased the risk of myopathy.46-49 3.4.4 Evidence use of ticlopidine hydrochloride for prevention of macrovascular and microvascular complications of diabetes mellitus A three-year double-blind, randomised-controlled trial involved 435 patients conducted by the Ticlopidine Microangiopathy of Diabetes study (TIMAD) investigators reported that ticlopidine significantly reduced the annual microaneurysm progression by 85% (p=0.03) and showed a preponderance to develop fewer new vessels (p=0.03) in the insulin-treated diabetic patients compared to placebo group. Significant reduction of overall retinopathy progression was also observed in the ticlopidine group (P=0.04).50 Ticlopidine-induced neutropenia (severe in one patient) with no clinical implications, rash or diarrhoea were reported during the treatment period.50 In another study with similar design, Early Treatment Diabetic Retinopathy Study (ETDRS) investigators demonstrated that aspirin had no effect on retinopathy progression in diabetic individuals.51 Due to its association with life-threatening neutropenia or thrombocytopenia, ticlopidine has been limited to patients who are aspirin-intole rant, or who have failed aspirin therapy.52-54 A meta-analysis included 10 trials with 26865 high vascular risk patients investigated the effectiveness of ADP receptor antagonists (ticlopidine and clopidogrel) versus aspirin in preventing serious vascular events in high vascular risk patients. The main outcomes of the trials are ADP receptor antagonists produced a similar significant reduction in the stroke and other serious vascular events compared to aspirin (11.6% vs 12.5%), ADP receptor antagonists significantly reduced gastrointestinal side effects and ticlopidine significantly increased the risk of neutropenia than aspirin.55 The meta-analysis postulated the fact that clopidogrel has a more favourable side effects profile than ticlopidine, therefore it is the thienopyridines of choice.55 4.0 CRITICAL APPRAISAL OF THE EVIDENCE BASED TREATMENTS CONCLUSION The therapeutic management of SARs AEBA is appropriate and SARs response to the treatment is good. Adding nebulised ipratropium bromide to nebulised salbutamol is important to improve the patients pulmonary function and to reduce hospital stay as both agents act rapidly to relieve bronchospasm. Initiation of IV hydrocortisone and short course of oral prednisolone is an essential treatment for AEBA as evidences support that the use of systemic corticosteroids significantly improves lungs performance, reduces relapse rate, hospitalisation and use of short-acting ?2-agonist following the outbreak of acute exacerbation. However, the dose of oral prednisolone should be adjusted to 40-50mg as according to guidelines to achieve the maximal benefits in relieving acute asthma. There are mounting evidences for the benefits of adding LABA to ICS instead of increasing the steroid dose when low dose ICS fail to control asthma symptoms adequately. Combined budesonide/formoterol inhaler has signi ficance in reducing severe exacerbation rates and in improving patient compliance. Patient compliance is of particular concern in this case as SAR with other co-morbid diseases requires polypharmacy. Therefore, Symbicort ® inhaler (combined budesonide/formoterol) should be given to SAR during hospital stay and as discharged medication replacing high dose ICS for the maintenance management of her asthma. The doctors action to start the empirical therapy of cephalosporins (ceftriazxone and cefuroxime) and macrolide (azithromycin) for management of pneumonia in SAR is appropriate as evidenced in clinical trials. These broad spectrum antibiotics have high bacteriological efficacy against the common pathogens implicated in community-acquired pneumonia. SAR was also on appropriate drugs for the management of chronic heart failure. Both furosemide and losartan have significant values in lowering the mortality rate and incidence of hospitalisation, in improving signs and symptoms and q uality of life of heart failure patients. Combination therapy of sulphonylureas and insulin is relatively safe and sufficient to control the blood glucose level of SAR as there are evidences of better glycaemic control and lesser or no differences in hypoglyaemic events as compared to insulin monotherapy. There is a preponderance of the evidences refuting the use of rosiglitazone in the diabetic patients with CHF as rosiglitazone has side effects profile (in particular peripheral oedema and associated cardiovascular risk) unfavorable to CHF patients. Therefore rosiglitazone should be withdrawn from SARs drug regimen. There are no studies concluded the superiority of ezetimibe and statin over fenofibrate and statin and both combinations are proved to have greater effects than monotherapy for secondary prevention of coronary heart disease in diabetic patients. However, the concurrent use of statin and fenofibrate may potentiate myopathy due to pharmacodynamic interaction. Moreov er, SAR had shown to have increased level of creatine kinase. Therefore, ezetimibe and statin should be the preferred combination as both agents do not have clinical interaction and optimal lipid lowering may best be achieved by inhibiting both synthesis and absorption pathways of cholesterol. The use of ticlopidine for the prevention of complications of diabetes mellitus is justified in this case as aspirin is contraindicated in asthmatic patient and ticlopidine has similar effects as aspirin for prevention of coronary and other vascular events. However, ticlopidine is associated with bone marrow toxicity. Therefore, careful haematological monitoring is required for SAR although she has been started on this drug for one year. In conclusion, the therapeutic managements of SARs presenting conditions are considered appropriate although some modifications need to be made to ensure that maximal benefits can be achieved without causing much clinical adverse effects. 5.0 PATIENT MEDICATION PROFILE PATIENT DETAILS Name SAR Consultant Not available General Practitioner Not available Address Not available Gender Female Weight 54kg Height 160cm Community Pharmacist Not available Date of Birth (Age) 54 Known Sensitivities NIL Social History Patient is a housewife. Patients siblings and children are suffering from bronchial asthma. No hx of alcohol drinking and smoking. PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date Day 1 -Patient experienced SOBx3/7(not relieved by taking inhaler), worsening on the admission day. Discharge Date Day 3 -Minimum cough with yellowish sputum, abdominal pain, diarrhoea, fever -No vomiting, no chest pain RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments Since childhood Bronchial asthma Before admission T. Rosuvastatin 20mg nocte Dyslipidaemia 3-4 years ago Hypertension Diabetes mellitus Ischaemic heart disease Before admission T. Ticlopidine hydrochloride 250mg OD (Ticlid) Prophylaxis against major ischaemic events Before admission T. Losartan 50mg OD Hypertension Before admission T. Gliclazide 60mg BD (Diamicron ® MR) Diabetes mellitus Before admission T. Fenofibrate 160mg OD Dyslipidaemia Before admission T. Ezetimibe 10mg OD (Ezetrol) Dyslipidaemia Before admission T. Rosiglitazone 4mg OD (Avandia) Diabetes mellitus Before admission T. Famotidine 20mg OD Prevent GI ulceration Since childhood MDI Salbutamol 200 µg 1puff prn Asthma Since childhood MDI budesonide 200 µg 2puffs bd Asthma Clinical/ Laboratory tests Date Results Plasma potassium (3.5-5.1mmol/L) Day 1 Day 2 5.1 5.0 Urea (1.7-8.5mmol/L) Day 1 Day 2 16.3 24 Creatinine (60-130 µmol/L) Day 1 Day 2 270 298 CrCL calculated (78-120ml/min) Day 1 17ml/min(severe renal impairment) Glucose random (11.1mmol/L) Day 1 18.8 Alb (35-50g/L) Day 1 34 Globulin (25-39g/L) Day 1 45 A/G ratio (0.9-1.8) Day 1 0.8 Hb (13.5-18g/dl) Day 1 Day 2 9.4 10.0 RBC (4-5.2)x1012/L Day 1 Day 2 3.4 3.6 Plat (150-400)x109/L Day 1 Day 2 410 400 WCC (4-11) x109/L Day 1 Day 2 17.1 10.8 Neutro (40-74)% Day 1 Day 2 96 86 Lymphocytes (19-48)% Day 1 Day 2 3 8 Monocytes (3.4-9)% Day 1 Day 2 1 6 CK (26-140)IU/L Day 1 156 LDH (240-480)IU/L Day 1 627 SpO2 Day 1 98%, pCO2 (4.8-5.8) kPa Day 1 4.3 pO2 (11.3-13.3) kPa Day 1 9.9 Pulse rate Day 1 111bpm Lung sound Day 1 Rhonchous PEFR Day 2 Day 3 200-220ml/min 250ml/min Chest x-ray Day 1 Shadowing in right lower zone Blood glucose readings (mmol/L) Time Date 0800 1200 1720 1100 Day 1 24.9 14.2 7.3 14.7 Day 2 15.8 12.4 19.7 16.2 Day 3 12.6 4.2 CLINCIAL MANAGEMENT Diagnosis Pharmaceutical Need Acute exacerbation bronchial asthma Neb salbutamol 5mg+ neb ipratropium bromide 500 µg+normal saline 4hourly, IV hydrocortisone 100mg stat,oral prednisolone 30mg od, MDI budesonide 200 µg 2puffs bd, Underlying pneumonia Antibiotics Chronic cardiac failure IV furosemide 40mg bd, Strict I/O chart(restrict fluid intake 800cc/day), low salt intake, KIV to start S/C Clexane if trop-T +ve Uncontrolled diabetes mellitus Insulin, Oral hypoglycaemics Ward medication Drug route Dose frequency Start date Stop date Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Day 1 Diabetes mellitus T.Rosiglitazone 4mg od Day 1 Diabetes mellitus T.Rosuvastatin 20mg nocte Day 1 Dyslipidaemia T.Fenofibrate 160mg od Day 1 Dyslipidaemia T.Ezetimibe 10mg od Day 1 Dyslipidaemia T.Lovastatin 20mg nocte Day 1 Dyslipidaemia T.Ticlopidine HCL 250mg od Day 1 Prophylaxis against ischaemic T.Losartan 50mg od Day 1 CHF T.Famotidine 20mg od Day 1 Prevent GI ulceration Neb ipratropium bromide 500 µg, salbutamol 5mg normal saline 2:1:2 qqh Day 1 Day 3 AEBA IV Hydrocortisone 100mg stat Day 1 Day 1 AEBA Neb Salbutamol 200 µg prn 1 puff prn Day 1 AEBA/chronic asthma MDI budesonide 200 µg 2 puffd bd Day 1 AEBA/chronic asthma T. Azitromycin 500mg od Day 1 Day 3 Pneumonia IV Ceftriaxone 2g stat Day 1 Day 2 Pneumonia IV Furosemide 40mg bd Day 1 Day 2 CHF S/C Atrapid 5? , 10? Day 1 Day 2 Diabetes mellitus T. Prednisolone 30mg od Day 2 AEBA MDI beclomethasone 200 µg 2puffs tds Day 2 Chronic asthma T.Cefuroxime 250mg bd Day 2 Pneumonia T. Furosemide 40mg od Day 2 CHF S/C Mixtard 30/10? Day 3 Diabetes mellitus Discharged medication Drug route Dose frequency Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Diabetes mellitus T.Rosiglitazone 4mg od Diabetes mellitus T.Rosuvastatin 20mg nocte Dyslipidaemia T.Fenofibrate 160mg od Dyslipidaemia T.Ezetimibe 10mg od Dyslipidaemia T.Lovastatin 20mg nocte Dyslipidaemia T.Ticlopidine HCL 250mg od Prophylaxis against ischaemic T.Losartan 50mg od CHF T.Famotidine 20mg od (6/52) Prevent GI ulceration Neb Salbutamol 200 µg 1 puff prn Chronic asthma MDI budesonide 200 µg 2 puffs bd Chronic asthma T. Prednisolone 30mg od (5/7) AEBA MDI Beclomethasone 200 µg 2 puffs tds Chronic asthma T.Cefuroxime 250mg bd (5/7) Pneumonia T. Furosemide 40mg od CHF S/C Mixtard 30/10? Diabetes mellitus PHARMACEUTICAL CARE PLAN Date Care Issues/ Desired outputs Actions Outputs Day 1 Confirm past medication history Ensure appropriate pre-admission medication continued and prescribed correctly. -Co-administration of rosuvastatin (pre-admission drug) and lovastatin (newly prescribed) together with other lipid-lowering agents are inappropriate. Confirm with patient that medicines given are correct. Ask patients family member to bring her old medication at home in order to confirm her medical history. Rosuvastatin should not be continued. (avoid in patients with CrCl ?30ml/min). Dose of fenofibrate should be reduced to 67mg od in patient with CrCl?20ml/min. (BNF) -Patients family members brought her medication at home and past medical history was confirmed. -Rosuvastatin and high dose fenofibrate were still given to patient. Day 1 Appropriate management of AEBA Any one of: -PEF 33-50% best or predicted -RR? 25/min -HR?110/min -inability to complete sentences in one breath -According to NICE/GINA guidelines, drugs for AEBA management include -Oxygen, nebulised beta2 agnonist, nebulised ipratropium bromide, IV hydrocortisone, oral prenisolone, inhaled corticosteroids Drugs indicated for AEBA were given. Oral prednisolone should be adjusted to dose of 40-50mg od for at least 5 days (BTS/GINA) Ensure close monitoring of PEFRs before and after bronchodilator treatment. Advise patient to avoid trigger factor (dust) Suggest self- monitoring of PEFR at home (PEF record keeping) -Dose of oral prednisolone was still not adjusted. -PEFR improved. Day 2 Management of chronic asthma -High dose steroids (MDI budesonide 200 µg 2puffs bd+ MDI beclomethasone 200 µg 2 puffs tds) -Local S/E: Oral candidiasis -Systemic S.E: Adrenal suppression, Cushings syndrome, precipitation of diabetes, oesteoporosis LABA should be added to ICS instead of increasing the dose of steroids. (BTS/GINA) Symbicort ® should be prescribed. Not done Day 1-Day 3 Poor compliance with monitoring and treatment (poor inhaler technique) To prevent subsequent attack: -Check inhaler technique -Education on the correct use of the newly-prescribed inhaler device. -Any observed deficiencies should be corrected before discharged. -Effective counselling of asthma management Simple written instructions reminders of when to use medication were given. The pharmacist checked SARs inhaler technique and SAR was educated to use MDI and nebuliser correctly during hospital stay. The pharmacist counselled SAR on the importance of adherence to drug regimen. Advised SAR to avoid trigger factor (dust) Should also be suggested to self- monitored PEFR at home (PEF record keeping) Counselled. Day 1 Appropriate management of pneumonia -IV Ceftriaxone 2g stat -Oral azithromycin 500mg od (3/7) -Oral cefuroxime 250mg bd (5/7) Monitored signs of recovery and WBC count. Repat CXR and look for progression/complications Replaced IV to tablet form when patient showed recovery of pneumonia. (BTS) Ensure completion of antibiotic course. Vaccinations against pneumococcal infection and influenza should be recommended. (BTS) -Patient showed signs of recovery. -On day 2, oral cefuroxime was given replacing IV ceftriaxone. -Patient was told to complete the course of antibiotic at home upon discharged. -Not done. Day 1 Appropriate management of CHF Furosemide was given to alleviate pulmonary oedema and ankle swelling. Restricted intake of fluid (800cc/day) Furosemide should be given orally with reduced frequency and total daily dose when the patient showed recovery of ankle swelling. Monitored plasma K+ level, renal function bp. Losartan 50mg od was continued. -Lungs were clear, no crepitation. -Swelling of ankle resolved. -Input/output restricted. -On day 2, IV furosemide 40mg bd was replaced by oral furosemide 40mg od. Plasma K+ decreased a bit on day 2 (5.0mmol/L), bp was under controlled. Day 2 Avoidance of hypokalaemia -High dose steroids + salbutamol+ furosemide increase the risk of hypokalaemia. Potassium chloride 600mg bd (appropriate dose for severe renal impairment pt) Close monitoring of plasma K+ level. -Not given. Day 1 Appropriate management of uncontrolled DM -Addition of insulin to the two oral hypoglycaemic agents after the dual oral therapy fails (Targets for blood glucose 4-7mmol/L pre-meal, 9mmol/L post-meal, target HbA1c ?6.5%, practically 7%) Mixture of short intermediate acting insulin was given. Close monitoring of blood glucose and HbA1c levels. Monitored signs of hypoglycaemia. Educated on proper insulin injection techniques -Blood glucose level was under control. No signs of hypoglycaemia. -Measurement of HbA1c was not taken. -Patient and her family members successfully demonstrated the use of insulin injection. Day 1 Safe use of rosiglitazone evidences refuting the use of rosiglitazone in the diabetic patients with CHF as rosiglitazone is associated with oedema, plasma volume expansion and increased cardiovascular risks. -Not recommended in patients with IHD or peripheral arterial disease, contraindicated with CHF and ACS. (EMEA,BTS) Rosiglitazone should be withdrawn. -Rosiglitazone was still given to patient. Day 1 Anaemia Hb (13.5-18)g/dL-9.4 RBC (4-5.2)X1012/L -3.4 -Anaemia is common in patients with moderate to severe HF. -Most likely exacerbated by administration of rosiglitazone. Withdraw rosiglitazone Monitor Hb and RBC If the anaemia problem is not improved, erythropoeitin and iron therapy can be considered. Not done. Day 1 Primary and secondary prevention of cardiovascular events and complications of DM Polypharmacy in the use of lipid-lowering agents. -Rosuvastain, lovastatin, ezetimibe,fenofibrate Rosuvastatin lovastatin act via the same mechanism of action. Dual therapy of statin and fenofibrate potentiate the risk of myopathy (pharmacodynamic interactions) Avoid rosuvastatin if CrCl?30ml/min Reduce dose of fenofibrate to 67mg od if CrCl?20ml/min Rosuvastatin and fenofibrate should not be given. (CrCl: 17m/min) Lipid profile should be done. LFTs should be carried out to avoid the risk of hepatotoxicity. Should advise patient to report promptly unexplained muscle pain, tenderness or weakness. -Four lipid lowering agents were still continued in the patient. -Lipid profile was not done. -No abnormalities of liver function. Day 1 Safe use of ticlopidine hydrochloride. -Similar efficacy as aspirin in reducing cononary and other vascular risk -Limited to patients who are aspirin-intolerant/ who have failed aspirin therapy. -Associated with bone marrow liver toxicity. Close monitoring of haematological LFTs should be done. Should be told how to recognise signs of blood disorder or jaundice. If adverse effects occur, clopidogrel can be considered (more favourable side effect profile). No signs of neutropenia, thrombocytopenia and liver abnormalities. Day 3 Patient for discharge Ensure appropriate medication prescribed and the patient is counselled appropriately prior discharged. Check discharged prescriptions against ward medication chart. Review the appropriateness of discharged medication. Ensure all information relevant to primary care included. Reinforced the importance of patient compliance and follow-up reviews. Counselled patient on the indications and possible side effects of those prescribed medications. Advised patient on healthy lifestyles: Regular exercise Adherence to balance diet which is high in oily fish, fruit, vegetables and fibre; low in calories, sugar, salt saturated fat. -Review of appropriateness of discharged medication was not done by the pharmacist. -Follow-up appointment was made and the patient was told. -Patient was given diabetic diet counselling prior discharged. Day 3 Self management education and personalised asthma action plans -Being able to monitor symptoms, PEF measurements, drug usage and knowing how to deal with fluctuations in severity of asthma according to written guidance. Should be offered self-management education that focuses on individual needs. (mentioned earlier) Should be given written personalised action plans. -No personalised asthma action plans was given.

Patriotism in Malaysia - 1747 Words

The Malaysian Bar Patriotism cannot be forced onto a Malaysian Contributed by Charles Hector The compulsory national service training programme is intended to foster the spirit of patriotism, encourage racial integration, and develop positive and noble traits among the younger generation (Malaysiakini 13/6/2003). The targeted group is our youth of about 18 years. The object of this programme was expressed by Defence Minister Najib Tun Razak, who chairs the special cabinet committee. The programme will focus on basic military training, patriotic training and personal development including community service. (Malaysiakini 17/6/2003) In the military, one is trained to follow orders of superiors without question. Would this be one of†¦show more content†¦Suppression of patriots kills patriotism. The announcement by the Minister of the removal of the controversial clause in the National Service Bill which makes it an offence to incite others from not participating in the programme was retracted due to complaints from the public (Malaysiakini 25/6/2003) must be applauded as a success for the cause for freedom of expression and as an example of a good leadership trait, ie of a leader that listens to voices of the Malaysian people. In tabling the Bill, the Minister was reported to have said that it is the responsibility of the people to ensure that multiracial Malaysia continues to be stable and strong to achieve development in view of various new attacks such as globalisation and liberalisation. Therefore, we cannot let the polarisation and alienated relation among races to continue. (Malaysiakini 25/6/2003). The national service training council is to have persons representing the major races. Malaysia is a multi-ethnic, multi-cultural and multi-religious nation. In Peninsular Malaysia, as an example, the major ethnic group cannot simply be said to be Malays, Chinese and Indians. Take Indians for example: they are in reality comprised of many ethnic groups like the Tamils, Telugus, Gujeratis, Punjabis, Malayalees and Goanese. Then there are also the Sri Lankan Tamils (Ceylonese)Show MoreRelatedWhat is Nationalism?796 Words   |  3 PagesI agree that the main reason for formatting nation-states is nationalism. Nationalism can be defined as a combination of patriotism with sensation of nation, it includes patriotism and nation concepts (Hayes 1960: 2). Kohn (1955) defines nationalism as a state of mind, each person will be piety to their state highly because of their nation-state (Berberoglu 2004: 6). 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Financial Planning (Insurance) Case Study free essay sample

Allison has recently been promoted by her employer, Best Marketing, and now earns $135,000 p. a. working full time. She has commenced salary sacrificing 30% of this amount into superannuation, and her employer contributes Superannuation Guarantee Contributions of 9% of her remaining cash salary. The fund is a balanced growth retail superannuation fund, MM Superannuation. Her current balance is $160,000 and earns on average 7% p. a. after fees and taxes. She also has $100,000 in term life and TPD insurance cover within her superannuation fund. She drives a 4-year old Land Cruiser that is fully paid for. It has low kilometres and she expects to keep it until she retires. She will then need $30,000 to purchase a new car on top of the trade in she expects to receive from the Land Cruiser. Simon works for Newbold’s Pty Ltd, a company which makes custom furniture. He earns around $45,000 p. a. and intends doing this work for the foreseeable future. He is supplied with a work vehicle and his employer pays his SGC based on his $45,000 salary. Simon has $47,000 in superannuation savings, held within the PP Superannuation Fund. The funds are invested in a balanced/ conservative portfolio with a low allocation to growth assets that earns around 4% p. a. after fees and taxes. They are living on a semi-rural property which is valued at around $750,000, but they currently have a mortgage of $150,000 as a line of credit. They are paying approximately $1,000 per month as interest-only payments. Their other personal expenses are around $40,000 p. a. and they spend an additional $15,000 p. a. on holidays. Aside from private health cover, car, and house and contents insurance, the only personal insurance they have is the coverage provided in Allison’s superannuation fund. They do not have a will or any powers of attorney but they want to ensure they have sufficient money for their grandchildren (now aged 6 and 4 years) to attend university. They estimate they will need to accumulate approximately $120,000 (in today’s dollars) over the next 12 years to pay for this. Allison wants to work for five or six more years and they wish to pay off the remainder of the mortgage over that time. She also wants to increase the amount of money in both her and Simon’s superannuation. When she retires she believes they will need $40,000 (in today’s dollars) for their living expenses in retirement, but Simon intends to continue working part time and estimates he will earn $20,000 p. a. They intend to use Simon’s income to fund any holidays. Aside from their superannuation assets, they have $9,000 in a bank account for emergencies earning 4% p. a. , $15,000 in a term deposit earning 5% p. a. and $12,000 in a cash management account earning 5. 5% p. . They are not happy with the taxation implications of these accounts, as any interest earned on the term deposit and cash management accounts seems to go in tax. You ascertain that they both have balanced risk profiles. Required: You are required to provide written responses to the following scenarios and questions, either in short answer form or using bullet points (or both). The following attachments are included : †¢ Sample Financial Services Guide (Personal Advice) †¢ Sample Fact Finder and Risk Profile Questionnaire †¢ Sample Ongoing Service Options – Establish Relationship with Client You are preparing for an initial interview with Simon and Allison Callahan. a) Give some thought to the sort of things you would cover. Include any legal requirements and other documentation which may be helpful in the interview. For the initial interview with the clients I would cover what Azza financial services stands for, their commitment to the customer and any legal implications, go over the financial services guide (send out with letter before hand) and privacy policy and compliance. I would also make the customers aware that the information they are providing is to be used solely for the purposes of assessing their situation to help them get to a better financial position. I would allow the customers to do most of the talking, recording their responses in a fact finder, and ask the client to complete a risk profile questionnaire to get a feel for what their financial position is at the present, what kind of expectations they have on Azza financial services, how much risk they are willing to take on and if there is anything about their situation that might prevent Azza financial from providing advice to the client. )How might you ask the client to prepare for the first meeting? By sending a confirmation letter indicating how long the interview will likely be, the purpose of the interview and what is the outcome intended, advising the client if there are to be any fees paid, providing the client with a list of documents to bring (eg current insurance policies, sup er statements, current investment schemes, income and expenses, latest tax returns, valuations of assets such as property, bank and credit card statements. ) To establish a relationship with Simon and Allison, what strategies might you use to build rapport during the interview process? †¢ offer food or drink (eg coffee, biscuits, tea, water) †¢ monitor client body language and engage in similar movements to make them feel more comfortable †¢ ask open ended questions to show clients you are interested in the personally and want to hear what they have to say. d)What are the four points you must cover when presenting a Financial Services Guide? Fees and charges = explain what fees might be applicable, including benefits and commissions that could be received by 3rd parties/referrers or product providers as a result of the plan being implemented †¢ Products = outline the features of the products and services being recommended †¢ Complaints Policies and Procedure s = make sure to completely explain the procedures for handling customer complaints †¢ Relationships = explain any relationships which might influence which products are recommended or provided e)List the type of fees you could charge the clients. What are the benefits of explaining these fees to the Callahans? Types of fees which could be charged to the clients if they choose to implement the prepared plan are: plan fees (often charged regardless if plan is accepted), commissions, entry fees, management fees, account keeping fees. The benefits of explaining these fees to the clients are that there will be no nasty surprises and they will know what they are getting themselves into from the start. It also provides protection for the advisor in the event that the client deems something unreasonable. In other words, there will be no misunderstandings about the possible cost of advice. )Nominate the range of financial products and services you will be providing advice in. Name the benefits of explaining these to your clients. The financial services and products which I could be providing advice on range from simplistic things such as bank deposit accounts to general and life insurance, complex and simple investment schemes, general and specialized superannuation schemes, estate planning issues (although a lot will be directed to a solicitor if I am not qualified to provide advice on that particular area, the same goes with taxation). The benefit of explaining these to the client is that they will be more aware of what it is Azza financial services can help them with, and if they will need to be involving any third parties to complete their requirements (eg accountant or solicitor). It also takes away any misconceptions as to the outcome of the advice provided and puts everyone on the same level expectation wise. The clients also may not have been aware of particular products and services offered which once explained may change their needs and requirements which might have not previously been considered by the client. )Outline the three steps your clients should take if they have a complaint or dispute prior to contacting the ASIC. †¢ Clients should first contact their advisor to make sure that their disatisfaction is not due to a misunderstanding or something which can be ammended to their satisfaction. I would endeavour to solve their complaint within 3 working days. †¢ If the clients are still unhappy , they should lodge a formal complaint with the liscensees internal complaints process and allow appropriate time for this to be acted upon. If the clients are still unsatisfied with the outcome they may then contact the Finance Industry Ombudsman Service (FOS) for complaints involving losses of less than $500,000. FOS first trys to negociate and outcome between the involved parties, if this is not possible the matter is passed for formal assesemnt by a panel. FOS is free to clients and the decisions it makes are law to the liscensee. 2-Identify Client Objectives and Financial Situation a) What techniques or tools could you use to gather further information about your client’s goals, objectives and financial situation? Fact finder †¢ Financial documentation – tax returns, statements, scheme overviews etc †¢ Use of open ended questions †¢ Diagnostic questionnaires †¢ Risk profiling b)Using your case study, complete the attached Fact Finder with as mu ch information as you can. Remember that this document is used to collect current information as well as identify any issues, problems or constraints that may be relevant in developing your advice. See Fact Finder i)From the scenario in your case study, write down one or more specific financial goals for the generic needs provided. Wealth creation for a specific purpose |Start increasing Allison and Simons Super balances ($160K and $47K) | | |Pay for grandchildren’s university in 12 years – estimated needed | | |$120K in today’s dollars | |Wealth protection |Take out Personal insurances to avoid eroding savings if something | | |unforeseen happens – income protection, trauma, evaluation of current | | life and TPD | |Debt reduction |Pay off IO mortgage of $150K in 5 years | |Tax minimization |Save on tax on bank accounts/term deposits | | |Possibly downsize family home and move mortgage to investment property| | |to save on tax | |Superannuation |Start in creasing Allison and Simons Super balances ($160K and $47K) | | |and evaluate suitability of current funds | |Investment Planning |Possibly purchase Investment property to produce another income stream| | |and save on current tax | | |Look into other investment options to diversify current wealth | |Estate Planning |Establish will and power of attorney with solicitor | c)Write down a line of questioning that you would use in the initial interview to increase your understanding and obtain further clarification of the client’s goals and objectives. Use open-ended questions starting with What, How, When, Why and Where. †¢ Apart from what we have already discussed, tell me about any other goals, long or short term that you might have. †¢ What do you plan to do when you retire? †¢ What is your current state of health? Eg do you smoke, are you aware of any issues that could affect your ability to work? †¢ Simon, what sort of duties do you perform at work? (- for insurance purposes we need to ascertain what type of work Simon is doing in order to now which category he fits, A/B/C? ) †¢ What are the contact details of your accountant? (- Financials) †¢ If you have a solicitor, what are their details? power of attorney, will) †¢ What are your plans/goals in relation to the planning of your estate? †¢ Tell me what other possible financial details you could have overlooked in filling out the fact finder? (- no credit cards? No shares or any investments outside of super and regular bank accounts? ) †¢ What level of cash reserve do you feel comfortable keeping liquid for emergencies, and are you expecting to receive a lump sum of money in the future? †¢ What are the premium details of your current life and general insurance policies? †¢ When are you considering downsizing the family home, if at all? d) What action would you take immediately after the first meeting? Immediately after the first interview I would Clearly write down everything which needs to be investigated or researched, in relation to what types of products, tax issues, possible strategies, the sources of information and a timeline for completion. This is so that I can prove I have been compliant with the corporations Acts requirement of investigating the ‘subject matter of the advice’. I would ask the clients to sign an authority accepting the preparation and research of drawing up a financial plan and agreeing to pay any fee which may be incurred as a result of this advice. e) Simon and Allison have a ‘balanced’ risk profile. Complete the sample Risk Profile Questionnaire to reflect this. See risk profile 3- Analyse Client Objectives Financial Situation Will Simon and Allison’s current financial circumstances and other concerns meet their objectives without your assistance? a) Why/why not? No, Simon and Allison’s current financial set up is not adequate to allow them to meet their goals and objectives. This is because they are note contributing enough in their superannuation to achieve their desired balances, they do not have any estate plans in place, their current bank accounts are leaving them paying excess tax, they are not sure how to structure their expenses in order to reach a comfortable position upon retirement in 5 years time, and their personal insurance are grossly insufficient to keep them in their current lifestyle and meet expenses should something happen to one of them. ) List the assumptions you made. †¢ Allison and Simon do not have current solicitor whom they have talked about creating a will or power of attorney with †¢ Allison and Simon are of average intelligence and have not had much to do with Financial planning services in the past. †¢ Allison and Simon do not know much about investment schemes, Superannuation regulations, Life insurance or Taxation †¢ Allison and Simon have used an Accountant in the past to prepare their yearly tax returns †¢ The average expected rate of return is 6% †¢ Expected CPI is 3% and current tax rates have been used. c) Reference information sources that you have relied on in forming your view. RG146 training Australia DFS course material and scenario †¢ Australian Taxation Office website (www. ato. gov. au) †¢ Financial Planning association website (www. fpa. asn. au) †¢ Westpac and BT Financial group case studies (internal) 4 – Develop Appropriate Strategies Solutions a) Describe two research processes you can use to gather information about products and services you recommend to your clients. †¢ Independent research houses (eg Standard and Poors and Morning Star) †¢ Internet searc hes eg ASX, AFPA, ATO etc †¢ Product disclosures, rankings, past performance of companies, Financial review newspaper etc Refer to your case study, Fact Finder and Risk Profile Develop a strategy for each of the following points for Simon and Allison. Describe each of your strategies in terms of key characteristics, advantages and disadvantages. b) Please address Allison’s insurance requirements. Your response should include a brief description of each type of cover and actual amounts recommended. Include calculations and explanations of amounts. †¢ Term Life: term life insurance provides a bulk payment to the beneificiaries of a person upon their death, or in some cases when disgnosed with a terminal illness the person insured can also received the payment. offered to people from 16-75 and can renewed until age 99. Can be paid via stepped premiums (where premium increases with age, you pay more in the long run) or level premiums (same amount througout policy, 30% cheaper than stepped in long run, and indexed to CPI) Advantages of having life insurance are that it gives the insured peace of mind knowing that they are not leaving their loved o nes in poor financial positions upon their death and ensures they are looked after Disadvatanges are that there are a few exclusions to the policy such as suicide within first 13 months, War, pre-existing conditions, aids, and terminal illness/disease where it is a direct result from an action which was self-inflicited. Currenlty Allison has $100,000 worth of life and TPD insurance within her superannuation. In regards to life insurance this is unfortunately inadequate as the estimated living costs for Allison and Simon are $67,000 per anum. In order for Simon to continue meeting these expenses (whilst still working) if allison were to becomed deceased, the insured amount would need to be close to $475,000. This is because if invested at an average fixed deposit rate of 6% it would provide an income stream of $28,500 per anum to Simon. [(475000/100) x 6 = 28,500] – this along with his current net salary of $38490 come to a per anum income strem of $66,990 to meet expenses. An additional $270K should also be added to cover their existing mortgage debt and to have money left over in order to pay for the grandchildrens university education, bringing the total life benefit to $745,000. †¢ Income protection: A fortnightly or monthly payment paid to the insured in the event that they suffer and injury or illness which leaves them unable to work Maximum of 75% of income can be insured and person must be employed at least 25 hours per week. Waiting periods of 14-720 dys apply and benefits periods can be 1-65 years (longer the beenfit period the higher the premium) 2 types of policies are agreed value (specified value to be paid regardless of difference between insureds current an d former incomes) indemnity (benefit based on insured income at time of claim. Advantages are that the insurance provides peace of mind knowing that if the insured was to suffer from an injury or illness and are unable to generate an income that the benfit will be paid as if it were their regular income, giving them peace of mind that they could stay on top of all their financial commitments and goals whilst healing. Disadvantges are that as income protection is linked to employment, those who are unemployed or even those with occupations which are considered too risky are not able to obtain income proteciton insurance. Also, as the benefit is only 75% of income, the insured will be 25% worse off and will need to make sure this will not affect any financial commitments or goals they may have. Allison currently does not have income protection insurance in place which could end diasterously as she earns 75% of the couples gross income. [(180,000/100) x 75 = 135,000)]. Allison should take out an income protection policy with a $101,250 benefit (135,000-25%) which would then provide both her and Simon peace of mind knowing that if anything was to happen they could continue paying their expenses †¢ Total and Permanent Disability: TPD insurance provides a lump sum payment to the insured after a qualifying period (usually six months) when certain criteria is met. Criteria can be inability to perform own occupation, any occupation, home duties or all duties; these are based on the type of work the insured is in (rated AAA-E) Immediate qualification for TPD payout if insured looses sight or a limb Advantages of having TPD is that if the insured suffers a debiltating injury that sees them unable to return to work that they can still meet their expenses Disadvantages are that it is not available to everyone; a new policy cannot be taken out after 60 and policies already in place automatically cease when insured reaches 65. Also unless rated category E, the standard level of cover criteria is ‘any occupation’, meaning that the insured may be able to perform in a role significantly less stimulating, challenging and financilally rewarding which would make them ineglibly to receive a payout even if they suffer a total and permanent diability. As Allison and Simons expenses are $67,00 p/a and Allisons income protection benefit is $101,250, whilst Allisons still working a stand alone TPD policy would be beneficial for having a lump sum to pay off the exisiting mortgage debt of $150K, have enough money to pay for the grandchildrens university ($120K) and possible medical expenses (another $150K) – totalling a $420K TPD. Another amount for Living expenses should also be considered for the 6 years until retirement ($67,000 x 6 years = $402,000). This brings the total recommended TPD benefit to $822K which could also be bundled as a rider on Allisons life insurance to avoid overinsurrance. †¢ Trauma: Trauma insurance provides the insured with a bulk payment when they suffer from an illness specified in the policy Can be bundled with life insurance and a payout will decrease the life policy by the same amount Available to people aged 16-55, or trauma for children aged 1-12 years ( waiting periods and age limit criteria apply) Advantages are that as trauma insurance is not related to employment, people with uninsurable occuppations can still generally take out trauma insurance. Also the insurance provides peace of mind knowing that if the isured was to suffer from a specified illness and are unable to generate an income that the sum paid will cover their expenses and ease the financial pressure Disadvanages are that there are exclusions such as death within 3 to 30 days of trauma event, trauma caused by an ntentional self inflicted injury or attempted suicide and acts of war. In order to avoid overinsurance Allison should take out around $250K trauma insurance to cover $150K exisiting mortage debt and any medical expenses associated with the event. Allisons Income protection will also most likely be able to contribute towards the benefit amount should a defined event occur. c)Does Simon require personal insurance? If so, what types and how much? Please include reasons and calculations Simon could take out the following polices to provide stability and peace of mind for Allison in the event something should happen to him. †¢ Term Life, Trauma, TPD: As Allisons income (or insurance benefit if something were to happen to her simultaneously) alone can support the couples expenses of $67,000, I would recommend a combined life insurance, TPD and Trauma policy, of $690K for Simon [(salary of $45,000 x 6 years = $27,000) + $150K mortgage debt + $150K possible medical espenses + $120K grandchildrens education = $690,000), so that the mortgage can be paid out, the grandchildrens education can be paid for, any medical expenses which might be incurred can be paid, and a replacement income stream for simon is created leaving allison debt free if something were to happen to Simon. †¢ Income protection: It is my view that Income protection is not necessary for simon as allisons income is more than adequate to support the couple with money left over, however if they did not want to draw on this, an income protection policy could be put in place for 75% of his income. [$45,000 x 75% = $33750 ($33750 / 12 = $2812. 5]. this would mean Simons monthly benefit woul be $2812. 5 (75% of his monthly income). D) What is the most efficient way for Simon to contribute to superannuation and why? How much should Simon contribute? As Simon is on the lower end of the income tax scale, it is beneficial for him to make non-concessional contributions into his superannuation as he is eligible for government co-contributions for every $1 he puts in up to $1000. As Allison is on a higher MRT than Simon, if she were to salary sacrifice a larger portion of her income into both their superannuation accounts (shes currently Sacrificing $40,000 into her own, however this could be brought up to $70,000 and then she could sacrifice another $20,000 per anum into Simons in line with their goals of increasing their super balances) they would be paying less tax (as Allison in on the highest MRT and super contributions are at 15%) and they can use Simons income (on lower MRT) to put towards their expenses, thus Simon should not contribute too from his salary above the SG of 9% and non-concessional contributions past $1000 (as his super will be paid in by Allison to achieve the above stated tax advantages). Simon should also switch his investment strategy to a balanced mix as it is too conservative to his risk profile at the present. e)Is Allison contributing sufficient funds to superannuation at this time to meet their retirement objectives? Please explain. To meet their objectives of having $40,000 per anum to live off in retirement, Allison is not contributing enough to her superannuation at this point in time. Allowing for the effects of compounding interest, after 5 years Allison’s superannuation balance would have accumulated to $224,400 (at 7%). In order to provide an income stream of $40,000 Allison will need to bring her balance up to $580,000 by the time she retires in 5 years. This means Allison will need to make up the difference ($580,000 $224,400 = $355,600) in the next five years. Allison will need to contribute another $30,000 p/a [($355,600/5 = $71,120) her current Salary Sacrifice of $40,500 = $30,000] to her superannuation to achieve this balance and their retirement objectives. Allisons current total superannuation contributions per anum are $40,500 in salary sacrifice (30% of salary of $135,000) along with a Superannuation guarantee of 9% of her remaining salary ($135,000 $40,500 = $94,500, $94,500 x 9% = $8505) bringing her total contribution to $49,005. f) Are their additional benefits available to Simon or Allison as a result of your strategies above? By Allison salary sacrificing more of her income she is saving astronomical amounts on tax as the contributions tax is only 15% as opposed to her MRT. As stated previously, Simon will also be eligible for the government co-contributions with his non-concessional contributions. Allison’s income protection policy (and Simons if taken out) are also tax deductible. Simon is also eligible for the low income tax offset of $804 from a maximum of $1350 for income earners of under $30,000. For Simon his amount is worked out with the following calculations: 1. [$1350 – ($45,000 taxable income -$30,000 threshold) x 4% = 546] and then 2. $1350 – 546 = $804) g)What is your recommendation regarding an investment for the grandchildren’s university education? What are the benefits of this investment? For the grandchildren’s education I would recommend investing in a balanced education savings plan (they would need to contribute $7000 p/a (at approx 7%, and with the effects of compounding interest) to reach their goal of $120,000 in 12 years) as the amount invested in taxed at a flat internal company rate of 30% however after 10 years the amounts can be withdrawn for non education purposes tax free, and as the investment is to be over 12 years Allison and Simon could take advantage of this. If it was to be withdrawn earlier, they are still in a good position as the money would be invested with a bit more risk than that of an everyday savings account and the taxation benefits still outweigh other methods, especially with the low income offset which is still said to be increasing. h) Are their bank/cash investments (total $36,000) meeting their requirements? Why/why not? What do you recommend? No, currently these investments are not meeting Allison and Simons requirements as they are held in both names and are therefore subject to Allison’s higher MRT. If Allison and Simon decided to use the advantages provided by income splitting (that is, transferring term deposits and interest bearing accounts into Simons name) then they would save on tax as Simon has a lower MRT. Allison and Simon could also think of putting this money in their Superannuation to capitalize on the 15% contributions tax or putting it into the mortgage as then they are paying less interest, however this would depend on whether or not they would be needing to keep this money liquid for everyday use and emergencies. i) How would you address their goals of paying out their home loan and purchasing the new car upon retirement? In order to pay out their home loan in 5 years time, Allison and Simon would eed to put around $40,000 P/A towards due to interest payable. After Allison’s extra salary sacrificing for both their Super accounts, the couple have around $45,000 surplus disposable income per anum. $40,000 can be used to make these extra payments on the home loan and the other $5000 can be put into a high interest savings account for the 5 years (which if invested at the average deposit rate of 6% will leave them with $29576. 10 after 5 years with the effects of compounding interest) which will leave them with enough money to purchase the new car. j) Are their estate planning preparations adequate? Why/why not? Currently Allison and Simon have no estate plan, therefore it being inadequate. I would recommend to Allison and Simon to contact their solicitor to discuss a will/power of attorney using their information we have uncovered through analyzing their financial situation here today. k)What alternative strategies did you consider? Why did you reject them? Insurance – providing insurances for Simon as well; This would be over insuring and wasting money for Allison and Simon as Simons income in relatively small in comparison to Allison’s, and she is able to cover all costs if something we to happen to Simon. Superannuation – Simon contributing more to his superannuation; the tax benefits of Allison’s salary sacrifice through decreasing her MRT far outweigh that of Simons and it was therefore better to prioritise with Allison’s SS and utilize Simon’s income for expenses. Investments – For the grandchildren’s university education, possibly investing in something more risky (eg shares) or less risky (eg Term deposits) however the tax advantages and return on the educations savings plan in comparison would leave them in a better position. 5 – Present Strategies and Negotiate Solutions Prior to Presentation a)Describe what preparations you would undertake to present your strategies in step 4 to Simon and Allison. After thorough research enabling me to form my recommendations, I would prepare a Statement of Advice with my findings, make sure to gather all product disclosure statements which are relevant, and information to back up my advice. I would also make sure there was a financial services guide within the information I would be taking to the interview. I would then call the clients to arrange a time which suits. b) What back-up information or documentation might you need? I might need to back up the performance of particular products/services I recommend (this could be provided in the form of company reports, asx reports, PDS, articles, academic studies etc) also easy to follow breakdowns of any calculations made so the client can see exactly how the strategy will benfit them. FSG and Privacy policy to assure the client of the companies principles and policies in the event of a dispute. During the Presentation c) Describe the disclosure principles and presentation requirements you must adhere to for the following documents: ? Statement of Advice The statement of advice must have â€Å"statement of advice† written across the front of it, it must be in non complex wording (â€Å"clear, concise and effective manner†), must have a â€Å"generic description of the range of financial products or strategies considered and investigated†¦Ã¢â‚¬ . The customer must receive a copy, along with PDS and FSG and must have signed and had the SOA presented to them BEFORE any implementation of strategies can be put in place. A disclaimer is also usually placed at the bottom of the SOA to protect the financial planner and affiliated companies against the working of case law – althogh this is not required by the corporations act. ? Product Disclosure Statement – The PDS needs to accompany the SOA so the clients have all the information in relation to possible products they are signing up to. Other things which need to be in the PDS include: Fees and charges = explain what fees might be applicable, including ben efits and commissions that could be received by 3rd parties/referrers or product providers as a result of the plan being implemented ? Products = outline the features of the products and services being recommended ? Complaints Policies and Procedures = make sure to completely explain the procedures for handling customer complaints ? Relationships = explain any relationships which might influence which products are recommended or provided d)List 2 objections or concerns your client might raise. How would you address these in order to gain agreement? 1. How do I know that what you recommend will work out for me in the long run? – We have based these recommendations on previous performance of these products and services, all of which you have sighted with your eyes. We cannot 100% guarantee that these potential outcomes listed will occur, however financial planning is what we specialise in and we make it our duty to look after your financial health. If we notice that the course which we have mapped out for you is not heading in the direction we have anticipated, you will be the first to know, and we will review your situation in order to alter your plan to best fit your needs, provided you would like us to provide you with this ongoing service. 2. This plan fee seems overly expensive – why do I have to pay it? – It takes a considerable amount of time, research, investigation and preparation for us to put together a plan that is tailored entirely according to your personal needs. There are no generics or assumptions made with what we are presenting you and the savings and earnings you will make as a result of our guidance will far outweigh the cost of this information. 6 – Implement Agreed Plan Simon and Allison have agreed to your plan. a) What transactional documents/authorities need to be signed by Simon and Allison? †¢ Authority to proceed / SOA and disclaimer †¢ Application forms along with PDS attached †¢ A cheque to be written to accompany application form b) Complete an Implementation Plan, in order, that details your planned actions now that Callahan’s have decided to proceed with your recommendations in step 4, providing an indication of when each must be completed. A Adviser C Client | No. Action |Who |When | | |Sign Authority to Proceed |C |Now | | |Provide 3rd parties with adequate notification of actions needed to be taken eg solicitor, accountant |A |ASAP | | |Complete application forms ready for client to sign |A |ASAP | | |Present application forms to client with PDS attached to be signed. |A + C |When ready | | |Photocopy, keep one and give other with PDS to client. | | | |Obtain Cheque from Client and attach to application form to be sent to dealer group |A |With step 4 | | |Welcome letter from dealer is issued |A /Dealer |- | | |Secure client file established (maintained for 7 years) |A |- | | |Confirm with clients that they have received welcome letter and they have heard from any 3rd parties. |A |- | | |Speak to clients about Review Service |A |When everything| | | | |is settled | 7 – Provide ongoing service You now have to address the issue of providing ongoing advice to Allison and Simon. )What environmental (economic, market, regulatory) changes, or changes to their personal or financial situation would cause a review of their plan? †¢ Interest rate changed may affect tax advantages, investment earnings †¢ New regulatory changes may grandfather or completely remove current strategies in place †¢ Market booms and busts may cause portfolio mix to be outdated / underperforming †¢ Clients may have suffered a loss, or injury causing them to claim and or need to reassess the financial commitments they can keep up with †¢ Clients may have come into a considerable amount of money unexpectedly allowing for more room to move in current strategy (e. g. inheritance, lotto) Change of advisor may bring upon new light on their situation, may have a better strategy in mind. b)Describe 2 activities you regularly undertake to keep up-to-date with current legal, ethical and regulatory requirements of the finance sector. †¢ Read financial review/finance news, current company legal updates †¢ Read the AFPA reports issued and newsletter from BT financial and liaise with current financial planners c)What level of ongoing service would you propose for these clients? ( â€Å"No service† ( â€Å"Portfolio valuation† ( â€Å"Port folio review† ( â€Å"Financial Plan review† ( â€Å"Other† Describe d)Describe the option recommended for your client, and why you have recommended this option. Describe the level of service you will provide and the associated fees. I would recommend an annual portfolio review for Allison and Simon to ensure that they are on track to achieving their goals. This would involve checking balances and fund mixes to ensure adequate returns have been made and that products are performing as anticipated. I would prepare a letter to send out based on my finding advising whether or not a change could benefit them. As the strategies recommended for Allison and Simone are fairly basic a separate fee would not be necessary as this service would be considered to be paid for under the trail commissions. Sample Fact Finder Risk Questionnaire 1. PERSONAL DETAILS |CLIENT 1 |CLIENT 2 | |Title: |Mrs |Mr | |Given Name: |Allison |Simon | |Preferred Name: |Allison |Simon | |Surname: |Callahan |Callahan | |Date of Birth: |1956 |1958 | |Marital Status: |M |M | | | | | Home Address: |Address: Lot 3 Wattle Road | | | | | |Suburb/Town: Hurstbridge | | |State: VIC Post code: | |Home Telephone No. | | |Preferred Contact No. | | | | | | | | CHILD / DEPENDENT DETAILS Name: |Megan | | | | |Relationship: |Daughter | | | | |Date of Birth: |1981 | | | | |Current Age: |29 | | | | |Financially Dependent: |NO | | | | HEALTH DETAILS Do you Smoke: |Yes / No |Yes / No | |State of Health: |Poor / Good / Excellent |Poor / Good / Excellent | |Are you aware of any health issues that may| | | |impact your ability to earn an income? | | | |(please provide details) | | | |Notes: | 2. EMPLOYMENT DETAILS |CLIENT 1 |CLIENT 2 | |Employment Status: |( Unemployed |( Unemployed | | |( Full Time Employed |( Full Time Employed | | |( Self Employed |( Self Employed | | |( Part-time |( Part-time | | |( Retired |( Retired | | |( Other |( Other | |Employer Name: |Best Marketing |Newbolds Pty Ltd | |Position Title: |Marketing |Employee | |Primary Duties: |Marketing |Custom Furniture | |Work Address: | | | |Current Work Phone No. : | | | |Employment Security: |Secure – just promoted |Secure – intention to stay long term | |Are you Contemplating leaving your employer? |In 5-6 years |Not in the foreseeable future | |Do you foresee any substantial change in |Planned retirement in 5-6 years, possible |In 5-6 years will reduce hours to part time | |your income in the next 2-5 years? reduction in take home pay in the lead up to|– income will be approx $20K p/a | | |this | | |Notes: | | | OTHER ADVISER DETAILS Accountant |Name: | | |Company: | | |Contact Detail: | | Do we have authority to contact? ( Yes ( No Solicitor Name: | | |Company: | | |Contact Detail: | | Do we have authority to contact? ( Yes( No ESTATE PLANNING DETAILS | |CLIENT 1 |CLIENT 2 | |Do you have a current Will? |No |No | |Date of Will / Last Reviewed: | | | |Power of attorney |No |No | |Type / Name of Attorney? | | |Do you have Funeral Plans? |No |No | |Do you have any specific intentions |Intention to pay for grandchildren’s |Intention to pay for grandchildren’ s | |regarding your estate distribution? |university in the approx 12 years (approx |university in the approx 12 years (approx | | |$120K in today’s dollars) |$120K in today’s dollars) | 3. FUTURE NEEDS OBJECTIVE AND GOALS |E. g. Current income needs, retirement income needs, diversification, tax minimisation, capital growth, investment security, wealth creation, | |eliminate mortgage etc | |Reasons for seeking financial advice | |Gain assistance with making the transition to retirement and planning the next five years | | | | | |Short Term (1 to 3 years) | |Save on tax on bank accounts/term deposits through possibly restructure | |Start increasing Allison and Simons Super balances ($160K and $47K) | |Look into other investment options to diversify current wealth | |Medium Term (4 to 7 years) | |Pay off IO mortgage of $150K in 5 years | |Buy new car (through trade in 9 year old land cruiser) worth $30K In 5 years | |Have a $40K (today’s dollars) p/a retirement income stream in 5 years | |Long Term (7 year plus) | |Pay for grandchildren’s university in 12 years – estimated needed $120K in | |today’s dollars | | | | | RETIREMENT PLANNING Retirement Details |CLIENT 1 |CLIENT 2 | |Plan ned Retirement Age: |59/60 |undetermined | |Retirement Income required: |$40K (today’s dollar) |$40K (today’s dollar) | |After retirement, do you intend to work |NO |Expected Income= | |again either on a full-time or part-time | |$20K | |basis? |Till age: undetermined | |What capital expenses will you have in |$ |$ | |retirement? (Please state expense and | | | |value) | | | |Would you like some assets left to your |$ |$ | |estate? Please detail) | | | |Notes: | | | | | 4. FINANCIAL DETAILS PERSONAL BALANCE SHEET Lifestyle Assets | |Owner |Date Acquired |Value |Associated Debt | |Principal Residence: |Allison and Simon | |$750,000 |$150,000 | Contents: | | | | | |Motor Vehicle/s : |Allison |2006 |Land Cruiser |No debt | |Caravan / Boat / Trailer: | | | | | |Investment Property: | | | | | |Other: | | | | | | | | | | | | | | | | | | | | | | | |Total | | | | | Investment Assets Investment | | | | | | | | | | | INCOME DETAILS | |CLIENT 1 |CLIENT 2 | |Income: |$135,000 |$45 ,000 | |Investment Income: |$1770 p/a interest (bank accounts) |$1770 p/a interest (bank accounts) | |Centrelink Income: | | |Pension/Annuity Income | | | |Other Income: | | | | Less Income Tax |$38554 |$7580 | | Less Medicare Levy |$2050 |$700 | |Total Net Income |$94426 |$38490 | |Combined Net Income |$132,916 | EXPENSE DETAILS |COMBINED | | |Food: | | | |Entertainment: |$15,000 | | |Transport/Vehicle: | | | |Council Rates: | | | |Amenities: | | | |Rent: | | | |Mortgage Repayments: |$12,000 | | |Other |$40,000 | | |Total |$67,000 | | SURPLUS DISPOSABLE INCOME | |COMBINED | | |Annual: |$65,916 | | |Monthly: |$5,493 | | PLANNED MAJOR EXPENSES |Nature of Expense |Approx. Expense Amount |Expected Date | |Grandchildren’s university |$120,000 in today’s dollars |12 years | |Purchase new car |$30,000 |5/6 years | | | | | | | | | |What cash reserve do you require for | | | |emergencies or unforeseen expenses? | | | |Are you expecting a future lump sum or | | | |inheritance? | | | |If so, how much? | | |Notes | | | 5. SUPERANNUATION INSURANCE SUPERANNUATION |Company |Policy No. |Employer/ Personal | |Are any of the above policies preserved? | |No | |Has a tax deduction been claimed for part/all? |Yes |No | |Are there any exit fees applicable? |Yes |No | LEAVE PAYMENTS Type |Expected Receipt Date |Anticipated Amount | |Annual: | | | |Long Service: | | | |Other: | | | |Have you recently received a redundancy package? |Yes |No | |If you have recently received a redundancy package, please provide notice of payments. | GENERAL INSURANCE Insurance Description |Policy Number |Owner |Date Commenced |Sum Insured |Premium Payable | |Term Life and TPD |Allison |$100,000 | | | | | | | | | | | | | | | | | | | | | | | | | |Notes: | | | 6. INVESTOR RISK PROFILE Your attitude to risk is probably the most important factor to consider before investing. To achieve higher returns, you will have to be prepared to accept a higher risk of capital loss. This is because the funds and assets that offer high returns are generally more volatile than those producing lower returns. It is what we call ‘risk/return trade off’. We will recommend investment strategies to match your investments to your risk profile. Investing across the various investment sectors according to your risk profile is called diversification. For example, instead of investing only in property, or only in shares, you might invest a proportion in both, or even include cash or fixed interest to create a balanced portfolio. You are a balanced investor who wants a diversified portfolio to work towards medium to long-term financial goals. You require an investment strategy that will cope with the effects of tax and inflation. Calculated risks will be accepted to help you achieve good returns. 17 – 23 Moderately Conservative – A Low Risk Taker You are a moderately conservative investor seeking better than basic returns, but risk must be low. Typically an older investor seeking to protect wealth that you have accumulated, you may be prepared to consider less aggressive growth investments. 9 – 16 Conservative – A Very Low Risk Taker You are a conservative investor. Risk must be very low and you are prepared to accept lower returns to protect capital. The negative effects of tax and inflation will not concern you, provided your initial investment is protected. 7. CLIENT STATEMENT / AUTHORISATION |I/We herby declare that the information set out in this form is true and correct to the best of my/our knowledge. | |I/We are not aware of any other information and have not disclosed to the person to whom this form is given any other information | |which would be relevant to the making of a recommendation by a Mentor Financial Planning Representative. | |I/We give permission for this information to be used for the preparation of my/our financial plan and I/we understand that the | |investment recommendations will be based solely on the information supplied in this form. | | |I/We also acknowledge that: | |( |I/we have received, read and understood the Financial Services Guide before any advisory services were provided; | |( |I/we permit this document to be passed in confidence to any member of Mentor Financial Planning Pty Ltd; | |( |Lim ited Information Provided | | |I/We have provided limited financial information. I/We have limited the product(s) or objective(s) that can be advised on | | |to: | | |If you are seeking limited advice of a particular nature you must make this known at the time of the interview and you | | |should recognise that the recommendations will only relate to that limited advice being sought and may not be appropriate | | |considering your overall situation and objectives. | |( |Tax File Number Permission | | |I/We give permission for my/our tax file number(s) as provided, to be held only by Mentor Financial Planning and be | | |forwarded to financial institutions as requested or as necessary. |( |Engagement Application | | |I/We request that Mentor Financial Planning investigate research and provide suitable options to the financial objectives | | |outlined in this questionnaire. | | | | | |I/We understand that the preparation fee of $500 is payable for the work to be undertaken. This fee may be credited | | |against my establishment fee should I/We proceed to implement any of the recommendations provided by Mentor Financial | | |Planning. | | |Client 1 | |Client 2 | | | | | |Signature: | | | | | | | | | |Date: | | | | |8. Adviser’s Declaration | I declare that: a) the information contained in the Fact Finder is an accurate and complete record of the information obtained from the client(s); b) The client(s) was provided with a copy of the Financial Services Guides before any advisory services were provided. |Adviser’s Signature | |Date | | | |Additional Important Information for the Client(s) | |If incomplete or limited financial information has been provided: | | | |I, as your Adviser, will not be able to undertake a full needs analysis of your individual investment objectives, financial situation | |and particular needs; | |There is a possibility that any recommendation given to you may not be fully appropriate to your individual objectives and needs, | |especially those which I, as the Adviser, do not know; and | |You as the client must carefully ssess the appropriateness of the recommendations to your own individual investment objectives, | |financial situation and particular needs before acting on them. | To Whom It May Concern Please accept this letter as my/our authority to provide any information requested and documentation if required to Azza Financial Planning (or their representative). Please accept a photocopy or facsimile of this letter, as the original will remain on file at the offices of Mentor Financial Planning. Correspondence should be sent to Level 2, 349 Collins Street Melbourne VIC 3000 This authority should remain in force until withdrawn in writing by me/us. Thankyou. |Allison Callahan | | | |Client 1 Name | |Signature | | | |Simon Callahan | | | | | |Signature | | |Client 2 Name | | | | | | | | | |Client 1 D. O. B. | |Client 2 D. O. B. | | | |___/___/___ | |___/___/___ | | | | | |Lot 3, wattle road, Hurstbridge, VIC | |Address | | | | | On Going Service Options 1. The â€Å"No serviceâ €  option This generally relates to a one off investment placement based on the agreed investment strategy in the financial plan. In choosing this option, no ongoing service or review of the financial plan and the investment portfolio is provided to the client unless specifically requested by the client or upon the recommendation of the planner. 2. The â€Å"Portfolio valuation† option This service provides reports on the value of your investment portfolio only. The fee charged will depend on the frequency of the reports. In choosing this option, no ongoing service or review of the financial plan is provided to the client unless specifically requested by the client or upon the recommendation of the planner. 3. The â€Å"Portfolio review† option This service provides reports on the value of your investment portfolio. The fee to be charged will depend on the frequency of the reviews and will be agreed at the time. The minimum fee is $N/A but this may be higher depending on the complexity of the review. This service includes: An annual/half yearly/quarterly review of your existing investment portfolio and its performance looking at further investment opportunities, if appropriate establishing if there have been any changes in legislation, the economic environment and state of the financial markets that may impact on your recommended investment portfolio In choosing this option, o ongoing service or review of the financial plan is provided to the client unless specifically requested by the client or upon the recommendation of the planner. 4. The â€Å"Financial Plan review† option This service provides for an annual/half yearly/quarterly review of the overall financial plan strategy and the investment portfolio recommend ed. Each review will be presented in the manner of a written report and recommendations. The fee to be charged will depend on the frequency of the reviews and will be agreed at the time. The minimum fee is $__500________, but this may be higher depending on the complexity of the review. This service includes: roviding reports on the value of your investment portfolio; an annual/half yearly/quarterly review (including comments) of your existing investment portfolio and its performance; looking at further investment opportunities, if appropriate; establishing if there have been any changes in legislation, the economic environment and state of the financial markets that may impact on your recommended investment portfolio and the overall financial plan strategy; establish if there have been any changes to your personal circumstances or financial goals and objectives; ascertain if the overall financial plan and the investment portfolio is continuing to meet your financial goals and objec tives (including an insurance review); and making any new recommendations (if necessary).