Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-05-23 Encounter: Spruce text message CC: Persistent cough, runny nose, and yellow nasal discharge for the entire month of May. HPI: Henry had been under the weather all of May with a mild cough and runny nose. By the week of 5/23, nasal discharge turned yellow and increased significantly in volume. He was waking up early and accepting medicine. Parent suspected either allergies progressing to a sinus infection or the other way around. One trial of Claritin was given and disliked. Parent also asked about giving an OTC cough/cold product to Jack (DOB 3/15/21, ~40 lbs) around 5/30. Assessment: Dr. Hobbs assessed that yellow nasal discharge after a prolonged course could represent allergies that progressed to possible sinusitis. Zyrtec was preferred over Claritin or Allegra. A nasal spray was also suggested for predominantly runny nose symptoms. Plan: Trial of Zyrtec (cetirizine) initiated. Nasal spray suggested as alternative/adjunct for runny nose. For Jack on 5/30, OTC cough/cold product (one appearing to be a diphenhydramine-based product) approved at 5ml (half of 10ml serving size). Medications: - Zyrtec (cetirizine) OTC, dose not specified - UNSPECIFIED OTC nasal spray, dose not specified - UNSPECIFIED 5ml OTC cough/cold liquid for Jack (diphenhydramine-based 'blue one'); serving size 10ml, starting at 5ml Key clinical quotes: "Very possible. Have you given him any thing for possible allergies?" "I like Zyrtec the best, then allegra" "if it's mostly runny nose, you could try a nasal spray" Source: Spruce conversation t_226ST10QO3800