Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-06-07 Encounter: Spruce text message followed by in-person home visit CC: Fever with worsening cough and low energy over the past 5 days, currently on Flovent and albuterol. HPI: Jack presented with a temperature of 101.6°F, cough that had worsened over 5 days, and low energy. He had previously been prescribed Flovent on 5/22 for a cough with yellow runny nose. His cough had improved initially but then worsened again. No ear pain reported. Parent administered albuterol approximately 20 minutes prior to contacting Dr. Hobbs. He was picked up from school. Assessment: Dr. Hobbs performed a home visit to evaluate Jack directly. Based on the clinical picture including fever, worsening cough over 5 days, and pre-existing respiratory treatment, an antibiotic was initiated. Post-visit, Jack slept through the night and fever resolved by the following morning. Plan: Dr. Hobbs conducted a home visit on 6/7. Prescription sent (medication unspecified). Follow-up check-in on 6/8 confirmed improvement — no fever, slept uninterrupted, minimal cough. Asthma action plan for school noted as pending. Continued Flovent 44mcg and albuterol. Medications: - Flovent 44mcg (pre-existing prescription) - Albuterol Not specified - UNSPECIFIED Prescription sent at/after home visit on 6/7 Key clinical quotes: "Tell me more about his cough? How's his energy? Did it seem like he was getting better or just staying the same or getting worse?" "Probably will be easiest if I come by and have a look at him after you get home." Source: Spruce conversation t_226ST10QO3800