Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2023-11-22 Encounter: Phone call via Spruce followed by Spruce text message with audio/video clip review CC: Child is sick with cough and wheezing requiring nebulizer treatments and steroids. HPI: Malcolm, age unknown, presented on 2023-11-22 with illness involving cough and wheezing, prompting same-day enrollment in the DPC practice. A phone consultation occurred that afternoon. By the evening, the parent was managing nebulizer treatments and had been prescribed prednisone and budesonide. Over the following days, cough improved, temperature normalized, and demeanor improved, though wheezing persisted somewhat due to a gap in nebulizer use. Assessment: Malcolm had respiratory illness with wheezing consistent with reactive airway disease/asthma exacerbation. By 2023-11-24, breathing did not appear labored on video review, and overall trajectory was improving on steroids and albuterol nebulization. Persistent wheezing was attributed to a gap in nebulizer treatments. Plan: Prednisone started immediately; budesonide deferred for a couple of days (held the first night). Albuterol nebulizer continued 2-3 times daily. Parent to monitor breathing effort, eating, and drinking. Follow-up via messaging confirmed improvement. Medications: - Prednisone Dose not specified (new) - Budesonide Dose not specified (new — held initially, to be added after a couple of days) - Albuterol Nebulizer, 2-3 times daily (new/ongoing) Key clinical quotes: "You can skip the budesonide tonight. We will add that in after a couple of days. I wanted you to have it in case it was needed sooner" "Not looking labored at the moment. How would you describe how he is now vs when we first talked, before the steroids?" "Let's keep the albuterol neb going 2-3 times a day. That part of the cough made fade a little slower" Source: Spruce conversation t_236OLKQGADG00