Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2026-07-05 Encounter: Spruce text message followed by in-person office visit and imaging (radiology study with contrast) CC: Projectile vomiting after every feed, worsening over the past 5 days. HPI: Macklin is an infant (weight approximately 12.5 lbs) with a history of spitting up, particularly after breastfeeding, that has worsened significantly over the past 5 days and now occurs after both breast milk bottle feeds and formula bottle feeds, with 5–10 episodes of projectile vomiting between every feed. Parent estimated vomit volume at approximately 1 oz per episode, occurring up to 10 times since 4:00 PM on 7/5. Associated symptoms include fussiness near feed times, green and unusually foul-smelling stools (no blood or mucus), and a subtle weight decrease to 12.5 lbs; no rash, and overall energy and disposition otherwise relatively unchanged ('happy spitter'). Family had traveled to a cabin for the Fourth of July holiday (8-hour round trip drive); no dietary changes in mother noted; parents were both feeling well. Assessment: Dr. Hobbs was concerned about the sudden worsening and escalation of vomiting from predominantly post-breastfeed to after all feeds, and wanted to assess volume and force to differentiate significant pathology from overfeeding/reflux. After the office visit and referral for imaging, results returned normal. The improvement seen with reducing feed volume (dropping the second bottle supplement and standardizing to 4 oz every 3 hours) suggested possible overfeeding as a contributing factor rather than a structural cause. Plan: Parent was asked to observe and quantify vomit volume overnight (7/5). An in-person office visit was conducted on 7/6. Imaging orders (radiology study, likely upper GI series given contrast use) were sent; parent scheduled the study for 7/8 and results were available by 7/9, reported as normal. Feeding was modified to 4 oz every 3 hours with elimination of the second supplemental bottle; Dr. Hobbs advised it was acceptable to offer 0.5–1 oz booster if infant showed hunger cues. Follow-up on feeding progress confirmed significant improvement in vomiting by 7/7, with only occasional spitting by 7/9. Green paste stool on 7/9 was attributed to contrast from the imaging study. Key clinical quotes: "Tonight. Take a shot glass and fill it up and dump it on a blanket. That's one oz. I'm trying to get a sense of the volume he's spitting up." "I'd think of it more as over eating, you described him showing you hunger cues and you fed him." "I'm glad we've got this info. How are feedings going?" Source: Spruce conversation t_2NMHFV8FSP800