Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-08-17 Encounter: Spruce text message CC: Diarrhea for several days, sore throat, ear pain, extreme thirst, and fever. HPI: Jack had loose stools since the prior Friday (approximately 4 days), progressing to soft but not urgent stools by the time of contact. The prior night he refused to eat, was lethargic, woke every 2 hours with extreme thirst, and complained of throat, stomach, and left cheek/ear pain. No fever captured at the time of initial message. He had been in a lake all weekend and attended swim lessons on Tuesday. No pain with ear manipulation. By the evening of 8/17, fever reached 102.5°F and throat was visibly red. Assessment: Dr. Hobbs noted that the preceding diarrhea made strep less likely but not impossible. Swimmer's ear was also considered but ear manipulation did not elicit pain. The 102.5°F fever and red throat on 8/17 evening confirmed a legitimate illness. Dr. Hobbs noted 'It would be wild for him to have two separate illnesses in a week,' suggesting the diarrhea and current throat/fever illness may be connected. Plan: Ibuprofen for fever and discomfort. Cold drinks. Monitor. Follow-up on 8/18 showed significant improvement — child reported as 'normal.' No antibiotics prescribed. Medications: - Ibuprofen OTC, dose not specified Key clinical quotes: "Well now, that's legit." "It would be wild for him to have two separate illnesses in a week" "Something cold to drink, some ibuprofen and let me know how the day progresses" Source: Spruce conversation t_226ST10QO3800