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: Malcolm, age approximately 3 years old, presented with 2.5 days of runny nose and persistent cough without fever, mirroring his brother Hendricks who shares his room. He was irritable. Parents had albuterol and budesonide at home. Breathing was noted to be fine. Assessment: Viral upper respiratory illness circulating in household, consistent with COVID, flu, or common cold. Absence of fever and normal breathing were reassuring signs. Plan: COVID testing recommended. Ibuprofen for aches and pain. Albuterol nebulizer to be used as cough medicine. Budesonide to be added twice daily if cough worsens. 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" "No fever and breathing ok is a good start." Source: Spruce conversation t_27C02FVS44O00