Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-12-06 Encounter: Spruce text message CC: 19-month-old with cold symptoms and ear pulling, concern for ear infection. HPI: Griffin, 19 months old and weighing 29 pounds, presented with a bad cold including significant runny nose, slight cough, and new onset ear tugging with complaints of ear pain. No fever was present. Parent had not yet administered any medication and was asking whether it was appropriate to give children's Motrin. Pain improved after Motrin was given. Assessment: Dr. Hobbs assessed ear pain and pressure as common with significant nasal congestion and not necessarily indicative of a bacterial ear infection in the absence of fever. He noted that ear infections frequently self-resolve and advised watchful waiting. Plan: Motrin 120 mg (6 mL) every 8 hours approved for pain and fever management. Parent advised to monitor for worsening ear pain or development of fever as signs that could indicate a bacterial infection requiring further evaluation. Medications: - Ibuprofen (Motrin) 120 mg (6 mL) every 8 hours (new) Key clinical quotes: "The pain and pressure happen all of the time with a bad cold. Infections will often have worsening pain and a fever." "Another thing to note is if there is an infection it has a high chance of self resolving." "Let me know if the pain worsens or a fever pops up." Source: Spruce conversation t_2GPR3H3CA4G00