Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-01-11 Encounter: Spruce text message followed by in-person home visit CC: Severe persistent cough unresponsive to nebulizer therapy, followed by recurrent fever, lethargy, and school dismissal. HPI: Hendricks, age approximately 5, had a severe cough that was not responding to albuterol or budesonide nebulizers. Steam shower was tried and provided some relief. No prednisone at home. He subsequently developed a low-grade fever (100.9°F at school), ongoing lethargy, and runny nose. The cough had partially improved by January 15th but he remained lethargic with sick tired eyes and was dismissed from school. He weighed approximately 58 lbs. No medication allergies; food-only allergies. A home visit was conducted on January 15th. Assessment: Persistent viral respiratory illness with reactive airway component; elevated dose of budesonide nebulizer indicated to reduce airway inflammation. Low-grade fever and ongoing lethargy on January 15th warranted in-person evaluation and antibiotic course. Plan: High-dose budesonide nebulizer: 4 vials in a single treatment (once only) to reduce inflammation. In-person home visit January 15th. Prescription sent (UNSPECIFIED antibiotic — 4 mL twice daily for 7 days). Medication reconstituted by parent with 38 mL added to bottle. Medications: - Budesonide 4 vials in one nebulizer treatment (one-time high dose) (adjust) - (Prescription sent — specific medication not documented in Spruce) Key clinical quotes: "If you have enough budesonide, give him 4(four) at one time" "Just once. It can help reduce the inflammation" "4ml twice a day for 7 days" Source: Spruce conversation t_27C02FVS44O00