B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 • DOB: 01 January 2004 • Gender: Male • Age: 7 years 6 months CC: Well visit today with parental concern about short stature Ht: 48” Wt: 48 lb Resp.: 18 Temp. 98 F HR: 74 Allergies: PCN Here with parents. Parental concerns about B. being the shortest child in class. They are concerned about his height. Denies any PMH of any significant illness. Mother’s height is 64” with menarche onset at 12 years of age. Father’s height is 72”. Father states he was shorter than other children and then he had a rapid growth spurt when he was about 16 years old. Other family members are normal heights per parents’ history. Vaccines are up to date. Denies any recent travel. Lives with parents and older sister, no pets. B. is not concerned about his height at this time. Is going to start 2nd grade in August. Does well in school. Has friends at home and school. No other concerns at this time. Well exam done today. Normal exam and normal development. Denies any medications. Review of growth chart shows: • Annual growth >4 cm/year. • Birth: Ht: 19” • 6.6 years old: Ht: 44.5” Labs/imaging: • NB screen at birth normal • XRay single AP view of the left hand and wrist • Labs: T4, TSH Now that you have completed your SOAP note for B.P., it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives. Write a 700-word reflection providing rationale for your completed SOAP note. Consider the interview information provided in the patient scenario as you: List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint. Provide a minimum of 3 rationales for the physical exam components performed. Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection. Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
