Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-12-23 Encounter: Spruce text message followed by in-person home visit CC: Worsening cough and congestion for over 2 weeks with vomiting and decreased appetite. HPI: Jack had a cough and thick runny nose for over 2 weeks. He vomited on Tuesday and Wednesday nights. Since Thursday, cough and congestion had worsened — cough was more frequent, intense, waking him at night, and harder to catch his breath. No fever captured. Very limited eating. Flovent and albuterol were being given twice daily. Family was in town until 12/27. Assessment: Dr. Hobbs conducted a home visit on 12/23, listened to Jack's lungs, and determined that antibiotics were indicated. Oral steroids were considered but not yet started pending response to antibiotics. Plan: Home visit performed on 12/23. Prescription for antibiotic sent (medication unspecified). Start antibiotics immediately; hold steroids unless worsening. Continue Flovent and albuterol twice daily. Antibiotic course: 5 days per 12/26 follow-up. Jack reported much better on 12/26. Medications: - UNSPECIFIED Antibiotic prescription sent after home visit on 12/23; 5-day course - Flovent Not specified, twice daily - Albuterol Not specified, twice daily Key clinical quotes: "We need to decide if he needs some oral steroids or antibiotics" "yes, please. don't start the steroids yet. let's chat if you think he's getting worse or not getting better." "Jack takes the meds for 5 days and is done." Source: Spruce conversation t_226ST10QO3800