Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-12-06 Encounter: Spruce text message CC: Congestion, headache, low-grade fever, and possible ear pain. HPI: Jack presented with significant congestion ('super moppy'), headache, and a low-grade fever of 100.9°F. He was putting his finger in his ear, had low energy, and did not eat lunch. He was also noted to be emotionally irritable. No change in breathing reported. Assessment: Dr. Hobbs was primarily concerned about ear or sinus involvement given symptom constellation. Breathing was reassuringly stable. If not improving by the next morning, an in-person evaluation was recommended. Plan: Sudafed recommended for congestion. Monitor symptoms. If not improving overnight/next morning, plan to reassess in person. Follow-up on 12/7 showed Jack wanting to see friends — no further escalation documented. Medications: - Sudafed OTC, dose not specified Key clinical quotes: "I'm glad his breathing is still not getting worse. Mainly I'm curious about his ears or sinuses" "If he's not snapping back tonight/tomorrow morning, yes, it would be good to check him out again" Source: Spruce conversation t_226ST10QO3800