Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-02-14 Encounter: Spruce text message CC: Runny nose, persistent cough, and irritability for 2.5 days, shared with sibling. HPI: Hendricks, age approximately 4 years old, presented with 2.5 days of runny nose and persistent cough without fever. He was noted to be very irritable and complained of leg pain. Both he and his brother Malcolm shared a room and had identical symptoms. Parents had albuterol and budesonide at home from prior use. Assessment: Viral upper respiratory illness, likely one of several circulating viruses including COVID, flu, or common cold. Absence of fever and normal breathing were reassuring. Leg aches consistent with viral myalgia. Plan: COVID testing recommended. Ibuprofen for aches and pain. Albuterol nebulizer to be used as cough medicine 2-3 times daily with one dose before bed. Budesonide to be added twice daily if cough worsens. Monitor for worsening. Medications: - Ibuprofen age-appropriate, OTC (new) - Albuterol nebulizer, 2-3x/day (new) - Budesonide nebulizer, twice daily if cough worsens (new) Key clinical quotes: "I'd use the albuterol for sure. Think of it as cough medicine, not just rescue medicine" "If the cough is worsening, add the budesonide twice a day" "Flu can make people super cranky, but almost always has fever" Source: Spruce conversation t_27C02FVS44O00