Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-01-20 Encounter: Phone Visit CC: High fever with leg pain and leg weakness, suspected influenza. HPI: Jack developed a fever of 103.7-104.1°F the prior evening. He first complained of leg pain around 5pm and overnight said his legs 'didn't work and felt broken.' He was very thirsty. No cough, sneezing, or runny nose initially (clear thin mucus noted later). Throat appeared red. Parent used a temporal thermometer which read up to 105°F — Dr. Hobbs directed use of ear/oral thermometer, which confirmed 103.8-104.1°F. Parent purchased an OTC flu test from Walgreens; result was negative (possibly due to inadequate technique or early illness). Assessment: Dr. Hobbs assessed Jack as almost certainly having influenza based on the high fever, myalgia (leg pain/weakness), and presentation pattern, despite the negative home flu test. He called the parent approximately 15 minutes after the initial message. Plan: Ibuprofen/Motrin for fever. Accurate thermometry (ear or oral) instructed. Monitor fever trajectory and symptoms. Check-in by dinner on 1/20 showed temp down to 101°F. By 1/21, fever resolved. Increased fluid intake reinforced. Medications: - Ibuprofen OTC, dose not specified Key clinical quotes: "He almost certainly has the flu." "The temp / forehead one aren't accurate" "I'm very glad the temp is down" Source: Spruce conversation t_226ST10QO3800