CASE STUDY. 10-YEAR-OLD
FEMALE, AVERY BROOK.
REASON FOR ENCOUNTER:
SLIPPING GRADES.
WITH A SOAP NOTE.
EXAM STUDY GUIDE. GRADED
A+. LATEST 2026 UPDATE.
,HISTORY
History of Present Illness (HPI):
• Avery Brook is a 10-year-old female brought to the clinic by her mother
for concerns about declining school performance.
• Symptoms have been present for several months and appear to be
gradually worsening.
• Previously earned good grades and completed schoolwork without
difficulty.
• Teachers report that Avery is frequently distracted during class.
• Has difficulty staying focused during lessons.
, • Often forgets assignments and classroom instructions.
• Frequently loses school supplies, books, and homework.
• Requires repeated reminders to complete tasks.
• Has trouble finishing assignments on time.
• Homework takes much longer than it did in the past.
• Easily distracted by noises, conversations, and activities around her.
• Reports that her mind often "wanders" during class.
• Has difficulty following multi-step directions.
• Struggles with organization of her desk, backpack, and school materials.
• Symptoms occur both at school and at home.
• Gets along well with peers and teachers.
• No recent changes in family situation or home environment.
• No recent stressors, trauma, or bullying reported.
• Appetite remains normal.
• Energy level generally normal.
• Sleep is adequate, although she occasionally has difficulty settling down
at bedtime.
Associated Symptoms:
• Inattention
• Distractibility
• Forgetfulness
• Poor organization
• Difficulty completing tasks
• Frequently losing items
Denies: