NR 602 Primary Care Pediatrics Case Solution
;Patient: Avery Brook, 10-Year-Old Female presenting with
"Slipping Grades" Topic: Attention-Deficit/Hyperactivity
Disorder (ADHD), Predominantly Inattentive Presentation
Contents: History, Physical Exam, Diagnostics, Assessment,
Plan, SOAP Note, & 40 Evidence-Based Q&A 2026
1. HISTORY
Chief Complaint
“Her teacher says she is ‘daydreaming’ all the time, and her grades have dropped from
B’s to D’s.”
History of Present Illness
Avery Brook is a 10-year-old female in the fifth grade who presents with her mother for
evaluation of declining school performance. Her mother reports that Avery was a solid
“B” student through third grade, but since entering fourth grade—and now fifth grade—
,her grades have “slipped dramatically.” Her teacher recently sent home a mid-quarter
progress report noting that Avery “rarely completes in-class assignments,” “stares out
the window,” “loses homework frequently,” and “makes careless errors on tests despite
knowing the material.” Avery’s mother initially attributed the behavior to laziness or early
adolescent “attitude,” but now wonders if something else is wrong because Avery
becomes tearful when confronted about missing assignments and insists she “forgets”
or “didn’t hear” the instructions.
Key historical features include:
• Inattention symptoms: Difficulty sustaining attention during lectures or
independent reading; avoids multi-step math problems; disorganized desk and
backpack; loses pencils, lunchbox, and glasses at least once daily; easily
distracted by classroom noise or hallway activity; forgets to turn in completed
homework.
• Hyperactivity/Impulsivity: Minimal. Avery does not fidget excessively, leave her
seat, or interrupt others. She is described as “quiet” and “well-behaved but
spacey.”
• Onset and duration: Mother recalls similar traits since first grade (difficulty
finishing coloring worksheets, losing jackets), but they were manageable until
academic demands increased.
• Impairment: Declining grades, low self-esteem, avoidance of school, and
strained parent-child interactions.
• Sleep: Sleeps approximately 8.5 hours nightly; mother notes occasional snoring
but no witnessed apneas or restless leg movements.
• Diet: Picky eater; consumes little red meat.
• Screen time: 3–4 hours daily on tablet/television after school.
Review of Systems
• General: No fevers, no unintentional weight loss, no fatigue beyond homework
frustration.
• HEENT: No frequent ear infections, no reported hearing difficulty, no squinting or
headaches.
, • Respiratory: Occasional snoring; no daytime somnolence.
• Neurological: No staring spells, no post-ictal confusion, no tics, no head trauma.
• Psychiatric: No pervasive sadness, anhedonia, or suicidal ideation; some
situational anxiety related to school; no hallucinations.
• Endocrine: No cold intolerance, constipation, or dry skin.
Past Medical & Developmental History
• Term vaginal delivery; birth weight 7 lb 4 oz.
• Developmental milestones achieved on time.
• No chronic illnesses; no hospitalizations or surgeries.
• Immunizations up to date.
Family History
• Father: “Always scattered,” never formally diagnosed; possible untreated ADHD.
• Older brother (age 13): Diagnosed with ADHD, combined presentation;
managed with methylphenidate.
• Mother: Generalized anxiety disorder (well-controlled).
• No seizure disorders, thyroid disease, or intellectual disabilities.
Social History
Lives with both biological parents and brother in a suburban single-family home. Middle
socioeconomic status. No recent moves, divorces, or deaths. Denies bullying. Enjoys
drawing and recreational gymnastics. No substance use exposure.
2. PHYSICAL EXAMINATION
;Patient: Avery Brook, 10-Year-Old Female presenting with
"Slipping Grades" Topic: Attention-Deficit/Hyperactivity
Disorder (ADHD), Predominantly Inattentive Presentation
Contents: History, Physical Exam, Diagnostics, Assessment,
Plan, SOAP Note, & 40 Evidence-Based Q&A 2026
1. HISTORY
Chief Complaint
“Her teacher says she is ‘daydreaming’ all the time, and her grades have dropped from
B’s to D’s.”
History of Present Illness
Avery Brook is a 10-year-old female in the fifth grade who presents with her mother for
evaluation of declining school performance. Her mother reports that Avery was a solid
“B” student through third grade, but since entering fourth grade—and now fifth grade—
,her grades have “slipped dramatically.” Her teacher recently sent home a mid-quarter
progress report noting that Avery “rarely completes in-class assignments,” “stares out
the window,” “loses homework frequently,” and “makes careless errors on tests despite
knowing the material.” Avery’s mother initially attributed the behavior to laziness or early
adolescent “attitude,” but now wonders if something else is wrong because Avery
becomes tearful when confronted about missing assignments and insists she “forgets”
or “didn’t hear” the instructions.
Key historical features include:
• Inattention symptoms: Difficulty sustaining attention during lectures or
independent reading; avoids multi-step math problems; disorganized desk and
backpack; loses pencils, lunchbox, and glasses at least once daily; easily
distracted by classroom noise or hallway activity; forgets to turn in completed
homework.
• Hyperactivity/Impulsivity: Minimal. Avery does not fidget excessively, leave her
seat, or interrupt others. She is described as “quiet” and “well-behaved but
spacey.”
• Onset and duration: Mother recalls similar traits since first grade (difficulty
finishing coloring worksheets, losing jackets), but they were manageable until
academic demands increased.
• Impairment: Declining grades, low self-esteem, avoidance of school, and
strained parent-child interactions.
• Sleep: Sleeps approximately 8.5 hours nightly; mother notes occasional snoring
but no witnessed apneas or restless leg movements.
• Diet: Picky eater; consumes little red meat.
• Screen time: 3–4 hours daily on tablet/television after school.
Review of Systems
• General: No fevers, no unintentional weight loss, no fatigue beyond homework
frustration.
• HEENT: No frequent ear infections, no reported hearing difficulty, no squinting or
headaches.
, • Respiratory: Occasional snoring; no daytime somnolence.
• Neurological: No staring spells, no post-ictal confusion, no tics, no head trauma.
• Psychiatric: No pervasive sadness, anhedonia, or suicidal ideation; some
situational anxiety related to school; no hallucinations.
• Endocrine: No cold intolerance, constipation, or dry skin.
Past Medical & Developmental History
• Term vaginal delivery; birth weight 7 lb 4 oz.
• Developmental milestones achieved on time.
• No chronic illnesses; no hospitalizations or surgeries.
• Immunizations up to date.
Family History
• Father: “Always scattered,” never formally diagnosed; possible untreated ADHD.
• Older brother (age 13): Diagnosed with ADHD, combined presentation;
managed with methylphenidate.
• Mother: Generalized anxiety disorder (well-controlled).
• No seizure disorders, thyroid disease, or intellectual disabilities.
Social History
Lives with both biological parents and brother in a suburban single-family home. Middle
socioeconomic status. No recent moves, divorces, or deaths. Denies bullying. Enjoys
drawing and recreational gymnastics. No substance use exposure.
2. PHYSICAL EXAMINATION
