Natural Language Processing in Theoretical Application :: essays research papers

Natural Language Processing in Theoretical Application Abstract:   Ã‚  Ã‚  Ã‚  Ã‚  In this paper, I will be discussing the creation and implementation of a device that will utilize the concepts of natural language processing and apply it to everyday activities. The device will be a carry-along unit that can be adapted to several devices a person would use everyday, like the car, items in the kitchen, and your computer. This device will be portable, compact, durable and adaptable. The device will not just adapt to any device however, the capability to interface with the device will have to be built into the objects that the device will interact with. I will discuss about this in length during the paper, as this will present the largest difficulty in making the device an actuality and usable. Another aspect I will also talk about is training. No natural language processing system is perfect, actually none are. The user must be trained with the system and adapted to the system to really make it work. This will require technicians to not only train the user to use the device and adapt it to the user’s products but also to provide constant technical support. In this design a preset lexicon must be set to make this design plausible. I will relate how big this lexicon can be and how flexible future designs of this lexicon will appear. I will also provide logical breakdowns of commands being used, with copious amounts of examples for several environments. I will also discuss where troubles could arise in the actual implementation of the product and what semantic flaws could occur with frequency. Finally, I will discuss the feasibility of this design and whether the market and the technology are ready for this kind of attempt at natural language processing software integration. Introduction â€Å"The Jacques Boxâ„ ¢ will knock your socks off! This revolutionary product will change the way humans use their everyday products forever. Want to change the radio station in your car without taking your eyes off the road? Wrist deep in cake batter and you need to preheat the oven? Tired of using the excuse that you’ve â€Å"only got two hands†? Well not anymore, with The Jacques Boxâ„ ¢, you can now activate anything from your car, your computer or even your whole kitchen with just the sound of your voice.† Sounds good coming across the radio, or being offered for three easy payments of 149.99, but the reality of this is much further then the present.

ACC557 †Financial Accounting Essay

1. Analyze each company’s history, product/services, major customers, major suppliers, and leadership and provide a synopsis of each company. The Coca-Cola (NYSE: KO ) vs. PepsiCo (NYSE: PEP ) war is one of the greatest rivalries in corporate history, just like Apple vs. Microsoft. Coca-Cola and Pepsi are the two most popular and widely recognized beverage brands in the world. They have been competing in the soft drink sector for over a century and both companies enjoy a high degree of brand consciousness globally. Both companies try to market as part of a lifestyle. At the same time, these two soda giants are among the most popular and respected dividend growth companies in the market, so let’s take a look at the Coke vs. Pepsi debate from an investor’s perspective. Coca-Cola uses phrases such as â€Å"Coke side of life† in their website, while Pepsi uses phrases such as â€Å"Hot stuff† in their web, to promote the idea that Pepsi is â€Å"in syn c† with the cool side of life. Ironically, both Pepsi and Coke have similar beginnings: both were created in the 19th century and both were the results of the experimental work of innovative pharmacists. Coke was created in 1886 by Atlanta pharmacist John Pemberton while Pepsi was developed in 1898 by North Carolina pharmacist and drugstore owner, Caleb Bradham. The history of Pepsi began with a man named Caleb Davis Bradham. He was born in Chinquapin, North Carolina on May 27, 1867. He graduated from the University of North Carolina at Chapel Hill and attended the University of Maryland, School of Medicine, around 1890. After returning to North Carolina, Mr. Bradham taught public school for about a year, and later opened a drug store on the corner of Middle and Pollock Streets in downtown New Bern. In 1902, Bradham launched the Pepsi-Cola Company in the back room of his pharmacy and on December 24, 1902 the Pepsi-Cola Company was incorporated in the state of North Carolina. The business began to grow, and on June 16, 1903,  Ã¢â‚¬Å"Pepsi-Cola† was officially registered with the U.S. Patent Office. In 1910 there were 250 Pepsi-Cola franchises in 24 states and in January of that year the Pepsi Cola Company held their first Bottler Convention in New Bern. In 1926, Pepsi received its first logo redesign since the original design of 1905. In 1929, the logo was changed again. In 1931, at the depth of the Great Depression, the Pepsi-Cola Company entered bankruptcy. Assets were sold and Roy C. Megargel bought the Pepsi trademark. Megargel was unsuccessful, and soon Pepsi’s assets were purchased by Charles Guth, the President of Loft, Inc. Today PepsiCo, Inc. (PepsiCo) is a global food and beverage company. Through the Company’s bottlers, contract manufacturers and other partners, the Company makes, markets, sells and distributes a range of foods and beverages in more than 200 countries and territories. PepsiCo is organized into four business units: PepsiCo Americas Foods (PAF), which includes Frito-Lay North America (FLNA), Quaker Foods North America (QFNA) and all of its Latin American food and snack businesses (LAF); PepsiCo Americas Beverages (PAB), which includes all of its North American and Latin American beverage businesses; PepsiCo Europe, which includes all beverage, food and snack businesses in Europe and South Africa, and PepsiCo Asia, Middle East and Africa (AMEA), which includes all beverage, food and snack businesses in AMEA, excluding South Africa. In 2011 the company had revenues of $66.504 billion and a net income of $6.462 billion. The company has around 29700 employees worldwide. PepsiCo is also listed on the NYSE and is also a part of the Dow Jones Industrial composite. Pepsi Co’s current chief executive is Indra Krishnamurthy Nooyi who has been at the helm since 2006. The history of Coca-Cola began with Col. John Pemberton. He was wounded in the Civil War, became addicted to morphine, and began a quest to find a substitute to the dangerous opiate. The prototype Coca-Cola recipe was formulated at Pemberton’s Eagle Drug and Chemical House, a drugstore in Columbus, Georgia, originally as a coca wine. In 1885, Pemberton registered his French Wine Coca nerve tonic. In 1886, when Atlanta and Fulton County passed prohibition legislation, Pemberton responded by developing Coca-Cola, essentially a nonalcoholic version of French Wine Coca. By 1888, three versions of Coca-Cola – sold by three separate businesses – were on the market. A co-partnership had been formed on January 14, 1888 between Pemberton and four Atlanta businessmen: J.C. Mayfield, A.O. Murphey; C.O.  Mullahy and E.H. Bloodworth. Charley Pemberton’s record of control over the â€Å"Coca-Cola† name was the underlying factor that allowed for him to participate as a major shareholder in the March 1888 Coca-Cola Com pany incorporation filing made in his father’s place. More so for Candler especially, Charley’s position holding exclusive control over the â€Å"Coca Cola† name continued to be a thorn in his side. Today The Coca-Cola Company is an American multinational beverage corporation headquartered in Atlanta Georgia. It is best known for its flagship product Coca-Cola. The Company owns or licenses and markets more than 500 nonalcoholic beverage brands, primarily sparkling beverages but also a variety of still beverages, such as waters, enhanced waters, juices and juice drinks, ready-to-drink teas and coffees, and energy and sports drinks. It owns and markets a range of nonalcoholic sparkling beverage brands, which includes Coca-Cola, Diet Coke, Fanta and Sprite. The Company’s segments include Eurasia and Africa, Europe, Latin America, North America, Pacific, Bottling Investments and Corporate. In January 2013, Sacramento Coca-Cola Bottling Company announced that it had been acquired by the Company. Effective February 22, 2013, Coca-Cola Co acquired interest in Fresh Trading Ltd. In November 2013, Coca-Cola Company and ZICO Beverages LLC announced that Coca-Cola has acquired the ownership interest in ZICO. The company offers more than 500 brands in over 200 countries and serves over 1.7 billion servings per day. The company’s stock is listed on the NYSE and it is a part of the DJIA, S&P index and the Russell 1000 index. The company had revenues of $48.01 billion in the year 2012 and a net income of $9.01 billion. Coca-Cola has a total asset base of $86.17 billion and 146,200 employees worldwide. Pepsi and Coca-Cola customers include authorized bottlers and independent distributors, including foodservice distributors and retailers. Both companies normally grant their bottlers exclusive contracts to sell and manufacture certain beverage products bearing the respective trademarks within a specific geographic area. These arrangements provide both companies with the right to charge their bottlers for concentrate, finished goods and bottled water (Aquafina & Dasani) royalties and specify the manufacturing process required for product quality (Wyatt, 2012). Since The Coca-Cola Company and PepsiCo do not sell directly  to the consumer, they both rely on and provide financial incentives to their distributors to assist in the distribution and promotion of their respective products. For the independent distributors and retailers, these incentives include volume-based rebates, product placement fees, promotions and displays. For their bottlers, these incentives are referred to as bottler funding and are negotiated annually with each bottler to support a variety of trade and consumer programs, such as consumer incentives, advertising support, new product support, and vending and cooler equipment placement. Consumer incentives include coupons, pricing discounts and promotions, and other promotional off ers. New product support includes targeted consumer and retailer incentives and direct marketplace support, such as point-of-purchase materials, product placement fees, media and advertising. Pepsi supplies its concentrates to restaurants that they have contracts with. Another market segment that Pepsi targets are grade schools, colleges and universities. PepsiCo main suppliers include; Sandora, Sadochok and Toma juice brands which supply Pepsi’s concentrate, while G.D Searle and company supplies PepsiCo with NutraSweet for PepsiCo diet soft drinks. Ball Metal Beverage Packaging produces Pepsi’s aluminum cans. Amcor produces PETS for Pepsi. It also manufactures plastic bottles for Gatorade (Wyatts, 2012). PepsiCo products generate approximately $108 billion in cumulative annual retail sales. Here are PepsiCo products which had revenues of over $1 billion as of 2009; Pepsi cola, Mountain Dew, Lays, Gatorade, Tropicana, 7up, Doritos, Lipton teas, Quaker foods, Cheetos, Miranda , Ruffles, Aquafina, Pepsi max, Tostitos, Sierra mist, Fritos and Walker’s. PepsiCo foods generated 63% of the net worldwide revenues while 37% of the revenue came from beverages in 2012. Pepsi brand generated the most revenues with about $20 billion in revenues, followed by mountain dew with around $12 billion, the others followed in the order they are listed in above with Walker’s potato chips being the last of the 21 brands listed above. PepsiCo distributes its own product in parts of Europe while it uses contract manufacturers in other areas (PepsiCo, 2013). The main target markets for PepsiCo include the age group 14-30 which has always been the main target market for Pepsi. Historically, Pepsi has always targeted teens with heavy advertising, teen-oriented ads. Coca-Cola customers include large international chains of retailers and restaurants and small independent  businesses. Coca-Cola works with them equally to create mutual benefit. Together with their bottling partners, they serve their customers through account management teams, providing services and support tailored to their needs. Coca-Cola’s suppliers offer different services from packaging, information technology services, bottles and package labeling. The Coca-Cola Company’s main suppliers include; Alcan packaging which offers plastic bottle labels, Alcoa plastic caps, and Cannon provides steam boilers, water treatment systems and plastic products. EDS provides information technology services to Coca- cola for its operation in Latin America. Coca-Cola purchases syrups and concentrates from TCCC and other licensors to manufacture products. They also purchase their raw materials, other than concentrates, syrups, mineral waters, and sweeteners, from multiple suppliers. The beverage agreements with TCCC provide that all authorized containers, closures, cases, cartons and other packages, and labels for the products of TCCC must be purchased from manufacturers approved by TCCC. Leadership at PepsiCo – Indra Nooyi is the CEO of Pepsi she describes her leadership style as â€Å"Performance with Purpose,† a mantra that has become central to the PepsiCo journey over these past seven years. Nooyi has chronicled five leadership lessons that together form the roadmap for global leaders in the 21st century (Snyder, 2013). 1. Balance the short-term and long-term. Today’s leaders are, all too often, driven only by short-term quarterly results, yielding decisions that are counterproductive for the longer-term health of the organization and society. Effective leaders must strike a balance. 2. Develop a deep understanding of public/private partnerships. Nooyi points out that many private sector leaders treat the public sector (NGOs, governments) as the enemy—and vice versa. † She believes that NGO leaders do their jobs as a â€Å"labor of love.†Ã‚  Treating them with respect and understanding, as opposed to distain and condescension can go a long way (Snyder, 2013). 3. Think global, act local. Nooyi argues this is not an outdated clichà ©, but instead, sounds advice that can yield innovative, out-of-the box solutions. She showed part of a nine-minute commercial video, produced for the 2012 Chinese New Year. 4. Keep an open mind to adapt to changes. The art of asking probing questions to facilitate dialog and exploration. All-too-often, leaders close their minds to dissent, cutting off much needed debate. To lead in an ever-changing world, Nooyi  says, leaders must adapt and stay nimble (Snyder, 2013). 5. Lead with your head and your heart. Leaders must develop deep emotional intelligence, and bring â€Å"their whole selves to work every day.† They must continually remind themselves that everyone who works for them is a unique human being and seek to strengthen this human connection and bond. Leadership at Coca-Cola is expected from the CEO Muhtar Kent. He runs his company by being an entrepreneur and focusing on cash. He calls his leadership philosophy â€Å"constructively discontent.† (Bhasin, 2012). – According to Kent his preferred description of his leadership – means ‘It’s all about an entrepreneurial mentality. Injecting entrepreneurial religion involves getting Coke’s 146,000 employees to think like owners. â€Å"People need to feel like they are chasing pennies down the hallway.† It’s about the respect for cash,† Kent told Sellers. His devotion to that manifests itself in many ways. For instance: And at Coke, managers have to pay $15 a month if they want to use their cellphones for personal calls (and yes, that rule applies to the CEO too). â€Å"When you don’t see cash, all sorts of things go wrong,† he told Sellers. â€Å"You overspend as an individual and overspend as a company.† Kent suggests that people need to be connected with the cash impact of choices and decisions in order to make rational choices. 2. Based on the stock price for the timeline listed below, present a graph that illustrates the stock price of each company. Indicate conclusions that can be drawn based on the trend: a. The day of its initial public offering b. January 1, 2012 c. January 1, 2011 d. January 1, 2010 PepsiCo’s initial public offering was $23 a share in 1999. Coca-Cola’s initial public offering was in 1919, by a consortium of businessmen led by Ernest Woodruff, Robert W. Woodruff’s father, purchased The Coca-Cola Company for $25 million. The business was re-incorporated as a Delaware Corporation and its stock was put on public sale on the New York Stock Exchange, with common stock at $40 per share, and preferred stock at $100 per share. The chart below shows the changes in the stock prices of the organization from January 1, 2010, January 1, 2011 and January 1, 2012. While PepsiCo has outgrown Coca-Cola in terms of revenue over the last five years, Coke is doing better than its rival when it comes to earnings-per-share growth over the same period. Coke has considerably higher profit margins than Pepsi, in the area of 21.8% at the op Even if both companies have seen decreasing margins due to bottler acquisitions over the last years, Coke’s dominance in drinks seems to provide an advantage when it comes to margins on sales. As incomes rise, so does health awareness. But does any of this actually matter to Coke and Pepsi shareholders? Pricing here is complicated. Coke may have the most valuable brand in the world, and Pepsi’s brands are also quite valuable. It is the value of these brands that allows the stocks to trade at premiums to the market even while their basic products are seeing weak demand. 3. Research and summarize at least two (2) news events (this may include mergers, acquisitions, or political issues) that occurred from 2010 to the present day and the potential impact on the stock price of each company. Indicate how this influences your investment decision related to the company. Events that occurred in 2013 and the potential impact to be on the stock price for both PepsiCo and Coca-Cola. A New York Times article, published October 1st 2013 by Keith Bradsher, expressed concern about land grabs related to the sugar industry and the companies that supplied from it. The advocacy group Oxfam has accused three big international food companies of buying sugar from what they described as a plantation that had unfairly taken land from farmers in Cambodia and Brazil without proper compensation (Bradsher, 2013). Oxfam, called on the food and beverage companies to disclose more about the sources of their sugar supplies. It contended in a report that sugar, soybeans and palm oi l were the three crops producing the fiercest competition for land by large, often foreign, investors. The group’s report assailed three companies by name: Coca-Cola, PepsiCo and Associated British Foods. Coca-Cola stated that it asked suppliers â€Å"to recognize and safeguard the rights of communities and traditional peoples to maintain access to land and natural resources. According to† Amanda Rosseter, a company spokeswoman, Coca-Cola does not buy sugar directly from farms but from larger suppliers. These purchases have included buying from Tate & Lyle Sugars, which in turn has bought limited quantities from Cambodia, but Tate & Lyle Sugars has already said that it has no further plans to buy from Cambodia. PepsiCo stated in a  statement that it also paid attention to social responsibility issues in its contracting. The company added that it had â€Å"reached out to the suppliers; they have assured us they are in compliance with applicable laws.† How will it impact the stock price of Coca-Cola and PepsiCo being associated with the idea of taking land away fr om indigenous poor people so they have access to cheap sources of sugar? In another New York Times article published December 12th 2013 by Stephanie Strom, PepsiCo sealed an unusual deal that goes far beyond the soda wars, PepsiCo is expected to announce soon that it is unseating Coca-Cola as the beverage supplier to one of the nation’s hottest restaurant chains, Buffalo Wild Wings (Strom, 2013). The deal, which will start with the introduction of Pepsi, Mountain Dew and other drink brands in 2014, is the biggest sign so far of how PepsiCo is deploying its thriving snacks business and Quaker, which it also owns, to offset declines in its traditional soda business. â€Å"But what this partnership does is give Buffalo Wild Wings a full access pass to all that PepsiCo has to offer.† And the deal also allows Buffalo Wild Wings to capitalize on PepsiCo’s relationships with major sports organizations like the National Football League and Major League Baseball. 4. Provide an overall financial analysis for each company that highlights the key characteristics for investment and how this may impact an investor’s decision. While PepsiCo has outgrown Coca-Cola in terms of revenue over the last five years, Coke is doing better than its rival when it comes to earnings-per-share growth over the same period. Coke has considerably higher profit margins than Pepsi, in the area of 21.8% at the operating level for the soda giant versus 14.3% for the salty snacks leader. Even if both companies have seen decreasing margins due to bottler acquisitions over the last years, Coke’s dominance in drinks seems to provide an advantage when it comes to margins on sales. Coca-Cola has also done better than PepsiCo in terms of reducing share count via stock buybacks; the company has reduced the amount of shares outstanding by 4.6% over the last five years while Pepsi has not managed to reduce its share count by more than 1.3% over that period. On the other hand, the trend could be reversing in the middle term as Pepsi’s buyback program for 2013 will likely have a bigger impact on shareholder’s returns. As of the third quarter of 2013 Coke had spent $2.8  billion in stock buybacks during the first nine months of the year, and the company is planning to end 2013 with a repurchase of between $3.0 billion and $3.5 billion for the full year. Pepsi is planning to end 2013 with nearly $3 billion in buybacks. Even if Coke repurchases $3.5 billion during the year, that would represent roughly 2% of the company’s $174.8 billion market cap. While Pepsi’s buyback would still be smaller in absolute terms, $3 billion would account for a slightly higher 2.3% of the company’s market value around $130.1 billion. Coke’s buyback program has been bigger in recent years, but the company may be losing that advantage over PepsiCo in 2013, so it’s hard to tell which company will return more capital to shareholders via repurchases in the coming years. 5. Based on your review of the financial data for each company, indicate the accuracy and reliability of the data for making investment decision. Provide support for your conclusion. When the ratios of the two companies are compared, Coca Cola has a higher return on asset ratio, a higher dividend yield and a higher dividend growth rate over the last five years. Coca Cola also has a higher P/E ratio but PepsiCo has a higher EPS compared to Coca Cola. From the above information I would advise an investor to buy Coca Cola stock as compared to PepsiCo. My recommendation is based on expected earnings from the stock in terms of dividends and dividend yield, return on assets and the P/E ratio. A higher return on assets shows that a company is utilizing its assets effectively and efficiently in generating earnings. A higher P/E ratio also shows that the investors expect more earnings from the stock. Both Coca-Cola and PepsiCo are Dividend Aristocrats, meaning they have been able to increase dividends over the last 25 consecutive years. Coke has an amazing track record of 51 consecutive dividend increases in a row, while Pepsi has a smaller but still impressive trajectory of 41 consecutive dividend increases. When it comes to dividend growth, however, Coke has a better trajectory than Pepsi over the long term, and the company also delivered a bigger increase for 2013 with a 10% hike versus Pepsi’s 6% dividend rise for the year. 6. Recommend which company you consider as the better investment for your client and how you will present your recommendation. Support your recommendation with data from your analysis. Recommendations for Investment – In order to make an investment in a particular organization, it is necessary for the investors to make sure  that, the investors consider certain key things. The points to be considered by the investors include earning per share, net income and trend in movement of the price of the security of the organization (Pogue, 2010). The price of the stock of the organization Coca Cola Company is $37.67 whereas; the price of stock of PepsiCo is $70.27. This shows that, PepsiCo has a better stock price in comparison to Coca Cola. The earnings per share of PepsiCo is $3.76 whereas, the earnings per share of Coca Cola Company is $1.91. PepsiCo has net income of $6443000 whereas; Coca Cola Company has net income of $8572000. Both Coca-Cola and PepsiCo have earned their rights to be among the most popular dividend growth names in the market due to their rock-solid competitive strengths and time-tested dividend growth trajectories. However, Coke has been able to deliver superior dividend growth over the last few years thanks to its higher profitability and earnings growth rates. Valuations are very similar so, for the same price of a Pepsi, I’m having a Coke. Therefore, from this, one can make a conclusion on the expected future earnings and capital gains. The information deducted from the ratios presented above show that Coca Cola is the best buy. This therefore, shows that before buying a stock there is a rigorous exercise that must be undertaken to gather financial information and from that deduct the effect that information will have on the stock prices. (Cardenal, 2013). References 1. Bhasin, Kim (2012). Coca-Cola CEO Muhtar Kent Explains Why Everything’s All About Cash. Retrieved on March 14, 2014 http://www.businessinsider.com/coca-cola-ceo-muhtar-kents-leadership-philosophy-2012-5 2. Bradsher, Keith (2013). Worried About Land Grabs, Group Presses 3 Corporations to Disclose Sugar Purchases. Retrieved on March 12, 2014 http://www.nytimes.com/2013/10/02/business/3-corporations-pressed-to-disclose-data-on-sugar-purchases.html?ref=pepsicoinc&_r=0 3. Cardenal, Andres (2013) Better Buy: Coca-Cola vs. PepsiCo. Retrieved on March 12, 2014 http://www.fool.com/investing/general/2013/11/06/better-buy-coca-cola-vs-pepsico.aspx 4. -Cola (2013). Bloomberg Business Week. Retrieved on March 12, 2014 investing.businessweek.com/research/stocks/financials/ratios.asp? 5. â€Å"History of Pepsi vs. Coke Rivalry at Rivals4Ever†. Rivals4ever.com.

Barrows and Pickell model of problem solving Essay

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