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The presented report concerns the current physical health condition of Jessie Lin, who is 16 years old and is in year 11. Jessie had participated in a bubble soccer match and on completion of the match appears to be sweating profusely and has a flushed skin. The report intends to draw on the recorded vitals of the patient for effective evaluation of the existing health condition.
The provided case scenario reports that Jessie’s vital assessment had been conducted at 1450 hours. The temperature (tympanic) has been recorded to be 38.5ᵒ C. The pulse rate had been recorded as 140 beats per minute. The respiratory rate was recorded to be 29 breaths per minute and the blood pressure was recorded to be 130/70mm Hg. Her previous clinical observation records as on 23rd March, reveals her BP recorded as 110/60, Pulse rate: 70, RR: 14 and temperature to be 36.8ᵒ C. Vitals recorded on 24th March, reveal her BP recorded as 112/60, Pulse rate: 74, RR: 12 and temperature to be 36.6ᵒ C.
In relation to the subjective data, Jessie’s T-shirt appeared soaked and she had a flushed skin. No previous medical history of Jessie is available as she was enrolled to the school a week ago. Jessie mentions feeling extremely hot and experiencing an accelerated heart beat.
On the basis of the current vital assessment, it can be said that the recorded temperature equivalent to 38.5ᵒ C is slightly elevated compared to the normal body temperature which is 37ᵒ C (Medlineplus.gov 2020). Further, the pulse rate has been reported to be 140 beats per minute which is significantly elevated from the normal range which is equivalent to 60 to 100 beats per minute (Medlineplus.gov 2020). The respiratory rate has been reported to be 29 breaths per minute which is elevated than the normal range of 12 to 20 breaths per minute (Medlineplus.gov 2020). Also, the blood pressure has been recorded equivalent to 130/70 mm Hg, which is elevated than the normal range 120/80 (Medlineplus.gov 2020). Therefore, drawing on the current vital assessment data, it can be said that physiological health status of the patient is impaired and not functioning in accordance to the normal range. This indicates an underlying physiological issue.
Further, the vitals recorded on 23rd March, 2020; suggests that the BP of the patient was lower than the normal range. However, the pulse rate, respiratory rate and the body temperature was recorded to be within the normal range. Also, the vital assessment recorded on 24th March, 2020 suggested that the blood pressure of the patient was lower than the normal range. The pulse rate, the respiratory rate and the temperature was recorded to be within the normal range.
It is worth noting in this context that the abnormality within the vital signs was recorded after Jessie had participated in a rigorous physical exercise activity. As per Patel and Zwibel (2019), it has been mentioned that in comparison to the resting state, the human body while engaging in a physical activity requires a substantial increase in terms of energy demand. During the resting phase, the nervous system of the body characteristically maintains a parasympathetic tone that directly impacts the cardiac output, respiratory rate as well as other metabolic processes (Patel and Zwibel 2019). On the other hand, the physical exercise characteristically stimulates the sympathetic nervous system and induced an integrated response from the human body (Patel and Zwibel 2019). The generated response is said to maintain an optimal level of homeostasis for meeting the increased demand in relation to the physical, cardiovascular and respiratory efforts (Matura et al. 2016).
The increased blood pressure, pulse rate and the respiratory rate post participation in the game of bubble soccer, suggests a potential issue of cardiovascular disease that requires further assessment for confirmation (Ionnidis 2018). High blood pressure is directly related to an increased pulse rate and respiratory rate and is triggered due to decreased cardiac output or an underlying cardiovascular disorder (Katsouli, Pandey and Goldberg 2019). Also, the current recorded blood pressure value of 130/70 is characterized as Hypertension Stage- I. Facial flushing and profuse sweating are symptoms that have been studied to be associated with hypertension (Bhupathiraju and Manson 2017). Therefore, the present health status of the patient can directly be associated with the symptoms of hypertension which is also indicative of an underlying cardiovascular issue.
In order to confirm a diagnosis and assist Jessie with an effective care plan, a number of additional assessments would be ordered. The first set of action that would be undertaken would comprise of taking a medical history of Jessie. This would assist with the evaluation if Jessie has a medical history of any cardiac abnormality or a cardiovascular disorder (Bozkurt et al. 2016). In addition to the same, the blood pressure would be undertaken in both the arms so as to estimate the difference (Bozkurt etal. 2016). Also, the blood pressure of the patient would be undertaken two to three times at intervals in order to confirm if Jessie is suffering from Hypertension Stage I.
Jessie would also be recommended for ambulatory blood pressure monitoring in order to confirm the diagnosis of hypertension stage I. The rationale for the same can be explained as the routine monitoring of the blood pressure for duration of 24 hours in order to confirm the condition of Stage I hypertension (Carey et al. 2018). In addition to the same, the height, weight and waist measurement of the patient would also need to be conducted for calculating the BMI in order to confirm if the resulting condition is triggered due to obesity (Katsouli et al. 2019). An assessment of the retina and the light-sensitive lining at the back of the eye would also be conducted. Further, a heart-assessment, abdominal assessment and a neck assessment would also be conducted.
Also, an assessment of the legs would be conducted for estimating fluid build-up or edema and the pulse rate of several areas would be recorded. The abdominal assessment via stethoscope would help to investigate if the blood within the abdomen is flowing through narrowed arteries (Ionnidis 2018). The next assessment would assist with the examination of distended neck veins, bruits within the carotid arteries or an enlarged thyroid that are tightly linked to hypertension (Bhupathiraju and Manson 2017). In addition to the same, lab tests such as urinalysis, ECG and a lipid profile would also be ordered in consultation with a physician for confirming the diagnosis (Ioannidis 2018).
Hence it can be concluded that the paper has critically analyzed the current condition of the patient in relation to the provided objective and subjective data. It has further drawn on the evidence based findings to suggest further assessments that can help confirm the diagnosis of the patient.
Bhupathiraju, S.N. and Manson, J.E., 2017. Hot flashes and the heart: an ongoing enigma. Menopause, 24(8), pp.871-873.
Bozkurt, B., Aguilar, D., Deswal, A., Dunbar, S.B., Francis, G.S., Horwich, T., Jessup, M., Kosiborod, M., Pritchett, A.M., Ramasubbu, K. and Rosendorff, C., 2016. Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the American Heart Association. Circulation, 134(23), pp.e535-e578.
Carey, R.M., Calhoun, D.A., Bakris, G.L., Brook, R.D., Daugherty, S.L., Dennison-Himmelfarb, C.R., Egan, B.M., Flack, J.M., Gidding, S.S., Judd, E. and Lackland, D.T., 2018. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension, 72(5), pp.e53-e90.
Ioannidis, J.P., 2018. Diagnosis and treatment of hypertension in the 2017 ACC/AHA guidelines and in the real world. Jama, 319(2), pp.115-116.
Katsouli, A., Pandey, T.S. and Goldberg, D., 2019. Consistency of Blood Pressure Control: a Useful Tool of Hypertension Assessment in a Vulnerable Population. Journal of general internal medicine, 34(12), pp.2711-2713.
Matura, L.A., Shou, H., Fritz, J.S., Smith, K.A., Vaidya, A., Pinder, D., Archer-Chicko, C., Dubow, D., Palevsky, H.I., Sommers, M.S. and Kawut, S.M., 2016. Physical activity and symptoms in pulmonary arterial hypertension. Chest, 150(1), pp.46-56.
Medlineplus.gov, 2020. Vital Signs: Medlineplus Medical Encyclopedia. [online] Medlineplus.gov. Available at: <https://medlineplus.gov/ency/article/002341.htm> [Accessed 30 April 2020].
Patel, P.N. and Zwibel, H., 2019. Physiology, exercise. In StatPearls [Internet]. StatPearls Publishing.
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