, Case Study Overview
Patient: Avery Brook
Age: 10 years old
Gender: Female
Grade: 4th grade
Chief Concern: Slipping grades over the past 6 months, from A/B average to C/D and incomplete
assignments.
This comprehensive guide provides expert-level History of Presenting Illness (HPI) questions, Review of
Systems (ROS), physical assessment, diagnostic workup, differential diagnoses, final diagnosis, and a
complete SOAP note aligned with Chamberlain NR 602 expectations.
Demographics & Presenting Context
• Ethnicity: Caucasian
• Primary language: English
• Living situation: Lives with both biological parents and a younger brother (age 7)
• School: Public elementary school, regular classroom with no prior special education services
• Referred by: Teacher’s concerns shared during parent-teacher conference; parents accompany
patient to clinic
Chief Complaint (CC)
“My daughter’s grades have been dropping, and her teacher says she daydreams in class and doesn’t
finish her work.”
— Reported by mother, Sarah Brook.
History of Presenting Illness (HPI)
Expert HPI Questions & Answers
Question Patient/Parent Response
“When did you first notice the change in
About 6 months ago, beginning of the school year.
grades?”
“What specific subjects are affected?” Math and reading comprehension most; also missing science assignm
Patient: Avery Brook
Age: 10 years old
Gender: Female
Grade: 4th grade
Chief Concern: Slipping grades over the past 6 months, from A/B average to C/D and incomplete
assignments.
This comprehensive guide provides expert-level History of Presenting Illness (HPI) questions, Review of
Systems (ROS), physical assessment, diagnostic workup, differential diagnoses, final diagnosis, and a
complete SOAP note aligned with Chamberlain NR 602 expectations.
Demographics & Presenting Context
• Ethnicity: Caucasian
• Primary language: English
• Living situation: Lives with both biological parents and a younger brother (age 7)
• School: Public elementary school, regular classroom with no prior special education services
• Referred by: Teacher’s concerns shared during parent-teacher conference; parents accompany
patient to clinic
Chief Complaint (CC)
“My daughter’s grades have been dropping, and her teacher says she daydreams in class and doesn’t
finish her work.”
— Reported by mother, Sarah Brook.
History of Presenting Illness (HPI)
Expert HPI Questions & Answers
Question Patient/Parent Response
“When did you first notice the change in
About 6 months ago, beginning of the school year.
grades?”
“What specific subjects are affected?” Math and reading comprehension most; also missing science assignm
