Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-07-21 Encounter: Photo review (throat images sent by parent) CC: Persistent cough with red throat and throat clearing since a possible COVID illness in early July. HPI: Henry had a persistent cough since a likely illness around the 4th of July, possibly COVID (family was in Montana, tested negative on 7/10 though other family members were positive). He was reportedly always hoarse and doing throat clearing. A child he was recently with at a cabin was diagnosed with strep on Tuesday. Walgreens reported being out of albuterol and Flovent for Henry. A photo of his throat was sent and reviewed by Dr. Hobbs. Assessment: Dr. Hobbs assessed the throat as 'a bit red.' Strep was considered less likely given the symptom pattern and exposure timing. A persistent cough in the context of possible post-viral illness was the primary concern. Albuterol inhaler was suggested for the cough but unavailable at the pharmacy. Plan: Try albuterol inhaler for cough. Prescription refills for albuterol and Flovent to be arranged. Referral to pediatric ENT (Dr. Micah Berman) was recommended and appointment scheduled for 9/12. Asthma action plan noted as pending. Medications: - Albuterol Not specified - Flovent Not specified Key clinical quotes: "I think the strep is less likely based on his symptoms and the exposure timing." "Awesome. Good pics. Looks a bit red to me." "Try the inhaler for the cough?" Source: Spruce conversation t_226ST10QO3800