Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2026-08-29 Encounter: Spruce text message followed by planned phone/video call (FaceTime) CC: Infant presenting with back arching, grunting, crying, and positional discomfort consistent with gastroesophageal reflux, worsening over time. HPI: August (Gus) is 3 weeks old. Parents first reported waking every hour at night with back arching, grunting, crying, squirming, and head rolling, with occasional spitting up and gas that transiently relieved symptoms. He was comfortable when held upright but consistently uncomfortable when horizontal. By 9/2 (approximately 4 weeks of age), symptoms had escalated — he was now arching, red-faced, and crying every few minutes regardless of position, dry heaving, and swallowing with a painful grimace. A concerning episode of junky/noisy breathing with apparent difficulty inhaling was noted early on 9/2. Parents also noted straining and crying before stooling. No cough, no change in feeding volumes noted. Assessment: Dr. Hobbs assessed the initial presentation as moderate gastroesophageal reflux, noting that positioning relief and absence of feeding interference were reassuring. As symptoms progressed to include positional-independent discomfort, dry heaving, painful swallowing, and a respiratory episode, Dr. Hobbs determined the symptom burden warranted pharmacologic treatment for reflux. Plan: Initial plan: positional management (avoid lying flat). As symptoms worsened, Dr. Hobbs decided to prescribe medication for reflux. Prescription sent to CVS in Lakeville on Kenwood. A phone/FaceTime call was arranged for 9/3 morning. Medication required compounding and was not immediately available at CVS; NP Catherine Watson communicated that it would need additional time. Dr. Hobbs noted he was out of town with NP Catherine covering. Medications: - (Prescription sent — specific medication not documented in Spruce) Key clinical quotes: "Good morning. All babies reflux to some degree. What your describing sounds more moderate." "it's consistent that if he's not horizontal, he's comfortable?" "ok, that's a very useful info actually, it seems positioning helps a lot and he's not having so much reflux that it's interfering with feeding" "I think it's reasonable to try some medicine for that amount of symptoms" Source: Spruce conversation t_2PO2SKK3H5G00