Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-08-01 Encounter: Spruce text message CC: Morning throat pain, excess salivation, and stomach pain on his birthday. HPI: Henry (turning 5) was complaining every morning at breakfast that his throat hurt. On 8/2, he additionally reported stomach pain, excess 'slobber,' and pain with swallowing. No fever. Throat appeared red on inspection. Normal bowel movements and appetite. Sleep was short due to birthday excitement. Parent had previously spoken with a child psychologist about Henry's emotions and was curious whether tonsils/allergies could be contributing. Assessment: Dr. Hobbs noted that tonsil/allergy issues could certainly be affecting sleep and causing mild throat irritation. ENT referral already in place was cited as appropriate next step. Possible allergies raised as contributing factor to morning throat symptoms. Plan: Continue ENT follow-up (appointment 9/12 with Dr. Berman). Consider allergies as a contributing factor. No new medications prescribed at this time. Key clinical quotes: "For sure they could be. Could mess with sleep, could have mild irritation. More reason to meet our ENT friend." "Allergies?" Source: Spruce conversation t_226ST10QO3800