2026 Pediatric i-Human Case Study: Avery Brook – Complete
Clinical Encounter 10 Year-Old Female Presenting with Declining
School Performance and Slipping Grades
,TABLE OF CONTENTS
1. Cover Page
2. Patient Profile
3. Chief Complaint (CC)
4. History of Presenting Illness (HPI)
5. Past Medical History (PMH)
6. Surgical History
7. Family History
8. Social History
9. Medications & Allergies
10. Immunization History
11. Review of Systems (ROS)
12. Physical Examination
13. Growth and Development Assessment
14. Vital Signs & Diagnostic Results
15. Differential Diagnoses
16. Diagnostic Testing & Management Plan
17. Disposition & Follow-up
18. Documentation and EHR Exercises
PATIENT PROFILE
· Name: Noah Thomas
· Age: 10 years, 9 months
· Gender: Male
,· Ethnicity: Caucasian
· Grade: 5th Grade (Middle School)
· Primary Language: English
· Accompanying Person: Mother (Lauren Thomas)
· Source of Information: Mother and patient are both present and reliable.
CHIEF COMPLAINT (CC)
“My teacher says I’m not trying hard enough, but I just can’t pay
attention. My grades are dropping.”
HISTORY OF PRESENT ILLNESS (HPI)
Noah Thomas is a 10-year, 9-month-old male brought to the pediatric
clinic by his mother, Lauren Thomas. The mother states she was asked to
come in by the school counselor to discuss a “significant decline” in
Noah’s academic performance and changes in behavior over the past 4-5
months. The mother reports the issues have become progressively worse
since the beginning of the 2025-2026 school year.
Onset & Duration: The family first noticed subtle changes about 6 months
ago, but the teacher’s report and recent report cards have made the issue
more apparent. The mother reports Noah used to be an “A/B student,” but
his grades have slipped to “C’s and D’s.”
Specific Problems & Context:
· Inattention: Mother reports Noah “just stares off into space” during
homework. He loses his pencil, eraser, and school papers multiple times a
week.
, · Forgetfulness: Frequently forgets to bring homework to school or bring
assignments home from school. He has forgotten his lunch money three
times this month.
· Behavioral Concerns: The teacher reports Noah is “fidgety” and often out
of his seat, but he is not aggressive. He interrupts conversations and has
trouble waiting his turn in group activities.
· Sleep: Mother reports Noah has been difficult to get to sleep at night,
often complaining of a “tummy ache” or “legs feeling jumpy.” He wakes
up tired and “fights” getting out of bed. He sleeps 7-8 hours per night but
appears unrested.
· Nutrition: Mother reports Noah is a “picky eater.” He often skips
breakfast and has a limited appetite for dinner, sometimes preferring to
eat simple snacks like crackers rather than meals.
Associated Symptoms & Changes:
· Vision/Hearing: Mother denies any complaints of double vision, squinting,
or difficulty hearing the television.
· Social: Noah has withdrawn from his usual soccer team, stating he
“doesn’t feel like playing anymore.” He prefers to play video games alone.
· Mood: Mother describes him as “grouchy” and “easily frustrated” with
tasks he used to complete easily.
What Makes It Worse: Long periods of sitting still, complex multi-step
instructions, late evenings.
What Makes It Better: Short, structured activities, one-on-one attention,
moving around or taking “brain breaks.”
Review of Systems Related to HPI:
No review of systems findings at this time, except those noted in the HPI.
PAST MEDICAL HISTORY (PMH)
Clinical Encounter 10 Year-Old Female Presenting with Declining
School Performance and Slipping Grades
,TABLE OF CONTENTS
1. Cover Page
2. Patient Profile
3. Chief Complaint (CC)
4. History of Presenting Illness (HPI)
5. Past Medical History (PMH)
6. Surgical History
7. Family History
8. Social History
9. Medications & Allergies
10. Immunization History
11. Review of Systems (ROS)
12. Physical Examination
13. Growth and Development Assessment
14. Vital Signs & Diagnostic Results
15. Differential Diagnoses
16. Diagnostic Testing & Management Plan
17. Disposition & Follow-up
18. Documentation and EHR Exercises
PATIENT PROFILE
· Name: Noah Thomas
· Age: 10 years, 9 months
· Gender: Male
,· Ethnicity: Caucasian
· Grade: 5th Grade (Middle School)
· Primary Language: English
· Accompanying Person: Mother (Lauren Thomas)
· Source of Information: Mother and patient are both present and reliable.
CHIEF COMPLAINT (CC)
“My teacher says I’m not trying hard enough, but I just can’t pay
attention. My grades are dropping.”
HISTORY OF PRESENT ILLNESS (HPI)
Noah Thomas is a 10-year, 9-month-old male brought to the pediatric
clinic by his mother, Lauren Thomas. The mother states she was asked to
come in by the school counselor to discuss a “significant decline” in
Noah’s academic performance and changes in behavior over the past 4-5
months. The mother reports the issues have become progressively worse
since the beginning of the 2025-2026 school year.
Onset & Duration: The family first noticed subtle changes about 6 months
ago, but the teacher’s report and recent report cards have made the issue
more apparent. The mother reports Noah used to be an “A/B student,” but
his grades have slipped to “C’s and D’s.”
Specific Problems & Context:
· Inattention: Mother reports Noah “just stares off into space” during
homework. He loses his pencil, eraser, and school papers multiple times a
week.
, · Forgetfulness: Frequently forgets to bring homework to school or bring
assignments home from school. He has forgotten his lunch money three
times this month.
· Behavioral Concerns: The teacher reports Noah is “fidgety” and often out
of his seat, but he is not aggressive. He interrupts conversations and has
trouble waiting his turn in group activities.
· Sleep: Mother reports Noah has been difficult to get to sleep at night,
often complaining of a “tummy ache” or “legs feeling jumpy.” He wakes
up tired and “fights” getting out of bed. He sleeps 7-8 hours per night but
appears unrested.
· Nutrition: Mother reports Noah is a “picky eater.” He often skips
breakfast and has a limited appetite for dinner, sometimes preferring to
eat simple snacks like crackers rather than meals.
Associated Symptoms & Changes:
· Vision/Hearing: Mother denies any complaints of double vision, squinting,
or difficulty hearing the television.
· Social: Noah has withdrawn from his usual soccer team, stating he
“doesn’t feel like playing anymore.” He prefers to play video games alone.
· Mood: Mother describes him as “grouchy” and “easily frustrated” with
tasks he used to complete easily.
What Makes It Worse: Long periods of sitting still, complex multi-step
instructions, late evenings.
What Makes It Better: Short, structured activities, one-on-one attention,
moving around or taking “brain breaks.”
Review of Systems Related to HPI:
No review of systems findings at this time, except those noted in the HPI.
PAST MEDICAL HISTORY (PMH)
