Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-05-05 Encounter: Spruce text message CC: Cough starting yesterday with runny nose. HPI: Hendricks, age approximately 4, developed a cough the prior day that persisted into the day of messaging, accompanied by a runny nose. The cough was described by the parent as sounding more 'normal' and not deep or barky like prior croup episodes. No nebulizer had yet been tried at the time of initial contact. Parents had albuterol and budesonide at home. Assessment: Viral upper respiratory illness with cough, less consistent with croup given the character of the cough. Home nebulizer therapy appropriate. Plan: Albuterol nebulizer 2-3 times per day with one dose before bed. Budesonide nebulizer twice daily. Rest advised; avoid exertion. Monitor for worsening cough. Medications: - Albuterol nebulizer, 2-3x/day with one dose before bed (new) - Budesonide nebulizer, twice daily (new) Key clinical quotes: "give the albuterol 2-3 times a day and make sure one of them is before bed" "give the budesonide twice a day" "let me know if the cough is worsening or worrying you" Source: Spruce conversation t_27C02FVS44O00