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.

            Recently travel to Connecticut to visit relatives.

Physical Exam (PE): 

•BP: 100/60, temperature: 102.5 F, RR 15, pulse 88, O2 SAT 99%

•General: Well developed, well nourished, no acute distress (NAD)

•HEENT: Normal fundi, PERRL, conjunctiva clear, TMs clear, nasal turbinate normal

•Pharynx: Erythema with white patches, tonsils 3+ with symmetric enlargement,

uvula midline. 

  Petechiae on soft palate. Mucous membranes moist.

•Neck: Supple, shotty anterior cervical lymphadenopathy

•Chest: Lungs clear, no retractions, wheezing, crackles, or distress

•Heart: Regular rate & rhythm, no murmur, gallop, or rub

•Abdomen: Soft, non-tender, no masses, no hepatosplenomegaly

•Neuro: Normal cranial nerves, DTRs, sensation, & coordination. No focal deficits. 

•Skin: Diffuse, fine, raised rash with mild erythema over trunk and back

•Extremities: Warm, 2+ pulses, <2 second capillary refill

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.