Professional Documents
Culture Documents
Problem Statement Example
Problem Statement Example
Chief complaint (CC): Larry is a 9 year old male with complaint of a sore throat.
History of Present Illness (HPI): Larry was completely well until he developed a sore throat in the middle
of last night. The throat pain woke him from sleep; Mom thought he felt hot-checked his temperature
and it was 104. With Tylenol his temperature came down to 101. Today he says he can’t swallow solid
foods, but he can drink. He has a headache (2/10) and a stomach ache (all over, “just a little). He
vomited once after he woke up this morning.
Review of Systems (ROS): Negative for weight loss, fatigue, cough, runny nose, difficulty breathing,
palpitations, joint pain, weakness, or dizziness. Voiding normally. One episode of vomiting. Brother was
also sick with a “cold” last week.
Past Medical History (PMH): Unremarkable. Full term birth.
Allergies: None known
Medications: Tylenol for fever
Social History: Lives with Dad, Mom, and 3 year old brother. No pets. No smokers.
•HEENT: Normal fundi, PERRL, conjunctiva clear, TMs clear, nasal turbinate normal
•Skin: Diffuse, fine, raised rash with mild erythema over trunk and back
Problem Statement:
9 year old male with unremarkable PMH presents with one day of acute sore throat,
fever, and one episode of vomiting. Positive for diffuse stomach ache as well as
diffuse, fine erythematic rash to trunk and back, palatal petechiae, pharyngeal
erythema & exudate, tonsillar enlargement, and anterior cervical lymphadenopathy;
negative for cough.