V/S: T=37.8 P=112 bpm R=30 bpm BP=85/50 mmHg
GA: Thai child female, thin, normal posture, normal gait, good conscious, good mentally, good cooperated.
Skin: good skin turgor, no ecchymosis, no petechiae, no spider nevi, no jaundice.
Nail: normal nail, pink, no spoon nail, normal finger, no clubbing of finger, no joint deformity, normal capillary refill.
Head and Face: normal shape, normal size, no trauma scar& lesion, no dandruff, smooth hair, a little hair loss, no moon face, no butterfly rash.
Eyes: not pale conjunctiva, no icteric sclera, conjunctiva not injected, pupils 2 mm. react to light symmetry both eyes.
Ear: external ear no mass or lesion, ear canal no abrasion or inflammation or tenderness, tympanic membrane intact
Nose: inferior turbinate congested, septum not deviated.
Mouth and throat: lip not dry, not pale no cyanosis, pharynx slightly injected, tonsils enlarged1+ not injected, uvula midline.
Neck: trachea not deviated, thyroid not enlarged, neck vein not engorged, movement no limitation or stiff neck.
Lymph nodes: Submanibular lymph node positive 1 cm both side.
Lung: adventitious lung sound ชนิด occasional rhonchi at left lower lobe.
Heart: point of maximum impulse (PMI) at 5th ICS and MCL, heart rate 112 bpm., regular rhythm, heart sound S1S2 normal; no murmur.
Abdomen: flat shape, no excision scar, no distention, soft, no guarding, no rigidity, no tenderness, no mass, liver and spleen not palpable, active bowel sound 8 bpm.CVA no tenderness.
Extremities: no pitting edema, normal knee joint, no tenderness, no crepitus.
Motor power: no weekness, grade 5/5 upper and lower extremity