Examination
NO (Current Illness): 5-year-old girl, fatigue, sore throat, fever. OA (Obstetric and Neonatal History): Second pregnancy, uncomplicated. Birth at 39 weeks, spontaneous vaginal delivery, cephalic presentation. Birth weight: 3100 g, length: 50 cm. No resuscitation required, normal postnatal adaptation. Past Medical History: Common respiratory infections. Vaccination: According to the standard vaccination schedule. Additional vaccine: TBE (tick-borne encephalitis). DIN (Past Infectious Diseases): Varicella (2024). Allergies: Strawberries. Hospitalizations, Surgeries, Transfusions: None. Injuries: None. Regular Follow-up: Pediatrician, Dr. Oříšek. FF (Physiological Functions): Normal urination. Regular bowel movements (once daily, well-formed, no blood or mucus). Currently has a reduced appetite and disturbed sleep. Physical Examination: Conscious, cooperative, oriented to place, time, and person. Febrile (39°C), eupneic, asthenic habitus. Pale skin, no jaundice or cyanosis, no pathological skin lesions. Normal skin turgor and capillary refill. Normal muscle tone, no signs of meningeal irritation.
Head: Normocephalic, non-tender on percussion. No tenderness at trigeminal nerve exit points. Pupils equal and reactive to light. Sclerae anicteric, extraocular movements full. Conjunctivae pale. Eyes, ears, and nose: No pathological secretions.
Oral cavity: Clean, tongue coated, midline protrusion. Throat: Red, swollen tonsils with bilateral exudates, more prominent on the right.
Neck: Enlarged lymph nodes along the sternocleidomastoid muscles.
Chest: Normal alveolar breathing, no abnormal breath sounds. No respiratory distress. Regular heart rhythm, well-defined heart sounds.
Abdomen: Flat, soft, non-tender, no palpable masses. No signs of peritoneal irritation. Present bowel sounds. Liver and spleen not enlarged. Negative bilateral renal percussion test.
Lower Limbs: No swelling, lesions, or petechiae. Genitals: Female, no abnormalities.
