Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-06-02 Encounter: Spruce text message CC: Fever with deep cough, runny nose, and stomach pain. HPI: Henry (approximately 4 years old, DOB 08/02/2018) presented with a deep cough, clear runny nose, stomach pain, fever, and low energy. Parent noted rumbling in his back when listening with ear to his back. He had no ear pain or sore throat. Ibuprofen improved his mood and energy. No prior medications beyond OTC. Assessment: Dr. Hobbs assessed likely small bacterial infection secondary to a viral illness, consistent with early or mild pneumonia ('Technically it sounds like he had a little pneumonia. That's really common.'). Plan: Prescription for amoxicillin sent to Walgreens (Vernon). Parent instructed to update Dr. Hobbs by dinner. OTC Delsym recommended for cough on follow-up. Dr. Hobbs monitored through 6/5 when cough was reported as improving. Medications: - Amoxicillin Dose not specified; weight estimated ~35 lbs - Delsym OTC, dose not specified Key clinical quotes: "Most likely he's got a small infection secondary to whatever virus made him sick to start with." "Technically it sounds like he had a little pneumonia. That's really common." "close enough. sending script now for amoxicillin" Source: Spruce conversation t_226ST10QO3800