Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-08-29 Encounter: Spruce text message followed by in-person home visit CC: Fever with red/swollen throat and photo of throat sent. HPI: Jack developed a fever starting around 11am on 8/29 with a red and visibly abnormal-appearing throat (photo sent). Dr. Hobbs conducted a home visit on 8/29. Fever persisted overnight through 8/31 reaching 103°F. By 8/30, itchy spots developed on his hands, feet, and diaper area, consistent with hand-foot-mouth disease. Tonsils appeared very swollen and red on 9/1. No known strep exposure at school. Assessment: Dr. Hobbs assessed Jack as having hand-foot-mouth disease based on the distribution of painful, itchy lesions on hands, feet, and diaper area with concurrent fever and throat involvement. Swollen, red tonsils were additionally noted on 9/1. A second home visit occurred on 9/1 with the option to treat for strep if positive. Plan: Oral Benadryl 5ml for itching/discomfort. Tylenol and Benadryl at bedtime. Push fluids (cold preferred). Aggressive fever management. Monitor rash — if worse in morning, keep home from school. Home visit on 9/1 to assess for strep and consider antibiotic. Prescription availability brought to visit on 9/1. Medications: - Benadryl 5ml oral - Tylenol Not specified Key clinical quotes: "sounds like hand/foot/mouth more. oral benadryl would help" "Tylenol before bed, push fluids, ideally cold" "Any allergies? I might bring some meds with me to offer you that option if he has strep" Source: Spruce conversation t_226ST10QO3800