English medical history of sore throat - domesticMedical Records for Admisson Medical Number 696235 General information NameZhang Yi Age thirteen Sex Female RaceHan NationalityChina Address NO23 Yunch

gence and behavior are normal for her age. 3.Vaccinations: Up to date with all vaccinations. Family history: No family history of chronic diseases or hereditary diseases. No family history of allergies or autoimmune diseases. Social history: The patient is a student in the sixth grade of a local elementary school. She lives with her parents and has no history of smoking or drinking alcohol. Review of systems: The patient complained of pharyngalgia, fever, and ulcer in her mouth. She denied any nausea, vomiting, abdominal pain, cough, or difficulty breathing. She also denied any joint pain, skin rash, or swollen lymph nodes. Physical examination: Vital signs: Temperature 38.5℃, pulse 100 bpm, respiratory rate 20/min, blood pressure 120/80 mmHg. General appearance: The patient appeared tired and weak, but was alert and oriented to person, place, and time. Head and neck: The neck was supple, and there was no palpable lymphadenopathy. The oral cavity examination revealed multiple ulcers on the oral mucosa and tonsils. The tonsils were enlarged and erythematous. There was no exudate or tonsillar asymmetry. The pharynx was erythematous but no exudate. Chest: Clear to auscultation bilaterally. Heart: Regular rhythm with no murmurs, rubs, or gallops. Abdomen: Soft and non-tender, with no hepatosplenomegaly or masses. Extremities: No cyanosis, clubbing, or edema. Neurological examination: Cranial nerves were intact, and there were no focal motor or sensory deficits. Assessment: 1. Pharyngitis with tonsillitis 2. Fever of unknown origin Plan: 1. Admit the patient to the hospital for further evaluation and treatment. 2. Obtain blood cultures and throat swab for bacterial culture and sensitivity. 3. Start intravenous antibiotics and antipyretics. 4. Provide supportive care, including hydration and nutrition. 5. Follow up with ENT specialist for possible tonsillectomy. 6. Monitor the patient's condition and vital signs closely