Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-10-16 Encounter: Spruce text message CC: Nagging cough for approximately 10 days, worse at night and in the morning, with runny nose. HPI: Hendricks, age approximately 5, had a persistent cough for approximately 10 days, predominantly nocturnal and in the early morning. He also had a runny nose. No fever was reported. Parents had been using albuterol nebulizer once or twice daily, which provided inconsistent relief. Budesonide was available at home. Albuterol supply was depleted. Assessment: Prolonged viral cough with nocturnal predominance, likely reactive airway component. Nebulizer therapy had been underutilized. Plan: Increase albuterol to 2-3 times daily. Add budesonide nebulizer twice daily. Prescription for albuterol refill called in to Excelsior CVS for Hendricks. Medications: - Albuterol nebulizer, 2-3x/day (new) - Budesonide nebulizer, twice daily (new) - Albuterol prescription refill sent to CVS Excelsior (refill) Key clinical quotes: "I'd do the albuterol regularly 2-3 times a day and the budesonide 2x a day" "Nighttime coughs can be super frustrating for everyone." Source: Spruce conversation t_27C02FVS44O00