Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-09-22 Encounter: Spruce text message CC: Pre-operative clearance needed for scheduled tonsillectomy and adenoidectomy on 9/29. HPI: Henry was scheduled for a tonsillectomy and adenoidectomy on 9/29 at Surgical Specialty Center of MN. He developed a mild cold starting the Friday before surgery (9/22 weekend), including runny nose and throat pain. He wet the bed (which parent noted only happens when he is sick). No cough, no fever. He had been using Jack's albuterol inhaler with the cold. COVID test performed — result negative per parent (though parent was uncertain about technique). Parent also requested Flovent and albuterol refills. Assessment: Dr. Hobbs assessed Henry's pre-operative status. The mild cold was noted and documented on the preop form. Dr. Hobbs communicated that the anesthesia risk from a cold is minimal unless lungs are significantly involved. Albuterol was to be administered in preop per surgical center request. Preop form was sent to Berman's office on 9/27. Plan: Preop physical/clearance form completed and faxed to Dr. Berman's office. COVID test recommended and performed (negative). Flovent and albuterol refills prescribed and sent to Walgreens Vernon. Albuterol to be given in preop per surgical team. Surgery proceeded on 9/29. Medications: - Flovent 44mcg (confirmed by parent) - Albuterol Not specified Key clinical quotes: "I'll note it on the preop. We want him to need it less before Friday" "The only risks are if his lungs are very involved with the cold and that risk is still tiny" "Preop was sent over yest. Let me know if there are any issues. Plan for a quiet weekend." Source: Spruce conversation t_226ST10QO3800