Demographics: Ashley is a 7-year old female. She is a student in elementary school.
Chief Complain: The patient has a fever and sore throat for the past 24 hours.
1. What additional subjective data would you collect from Ashley and her mother?
• History of present illness
 Dental pain, mouth lesions: Ashley doesn’t have dental pain, but she has lesion in the mouth, especially in the larynx. She is suffering from pain in the throat. It means, she might have laryngitis.
 Dentures or dental appliances: Ashley doesn’t have dentures or dental appliances.
 Medications / herbal supplements: She doesn’t have medications / herbal supplement. She doesn’t use any medications and herbal supplements.
 Pain with swallowing: She has pain with …show more content…
 Frequent streptococcal infections: She did not have frequent streptococcal infections.
 Surgical history: She did not have surgical history. She has never been hospitalized.
• Family History
 Allergies: Nobody in her family member has been allergy history.
 Family surgical history: Nobody in her family member has been surgical history.
• Personal and Social History
 Excessive sugar intake: She like sweets, but she doesn’t take too much sugar.
 Oral care patterns: She just uses a toothbrush and toothpaste.
 Tobacco use: She doesn’t use tobacco. There are no smokers in her household.
 Potential exposure to pathogens: She is potential exposure to pathogens because other children in her classroom have been ill with similar symptoms.
2. What body systems will you plan to focus upon during your physical examination?
First of all, I will focus on the mouth and oropharynx system during my physical examination. Secondly, I will focus on the ears, nose, and throat during my physical examination. Finally, I will focus on the neck, lymph node, eyes, and head throughout my physical examination.
3. What objective data would you need to collect during your