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Examination of the mouth, sometimes referred to as the window to a patient’s general state of health, revealed good oral health with pink healthy, hydrated mucosa and tongue and no indication of cyanosis (Green, 2015).
The throat examination consisted of inspecting both the soft and hard palate for discolouration, inflammation, assessing the tonsil and uvula for symmetry, swelling, lesions or any abnormalities. (Bickley, 2013 and Hathorn, 2018). The examination revealed no deviation of the uvula or any abnormalities suggestive of a malignancy or of peritonsillar or tonsillar abscess (quinsy) (Gottlieb et al., 2018). Neither were there palatal petechiae or a “strawberry “red tongue, which would have been suggestive of scarlet fever (Patel et al., 2019; Ebell et al., 2000 and Gottlieb et al., 2018). However, there was generalised erythema of the pharynx and uvula, the tonsils were enlarged, swollen and “beefy” red, with punctate whitish exudate, and Lucy’s breath was offensive.
The process of physical examination concluded with a head and neck examination, with palpation for signs of lymphadenopathy (Hathorn, 2018 and Green, 2015). The presence of enlarged lymph nodes could be suggestive of an infective or malignant process (Dower et al., 2018). The anterior cervical nodes were enlarged and tender, especially at the angle of the jaw, known to be common with tonsillitis (Gottlieb et al., 2018; Ebell et al., 2000 and Green, 2015). No lymphadenopathy was noted in the submental nodes and pre-auricular nodes.