Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-07-03 Encounter: Spruce text message CC: Fever of 102°F, runny nose, and lethargy over the 4th of July holiday weekend. HPI: Malcolm, age approximately 3, developed a fever of 102°F and runny nose simultaneously, with no cough or vomiting. He was very sleepy. Tylenol was given and reduced the fever effectively. He was tolerating fluids well. Parents were staying home for the holiday weekend. He was noted to have woken a few times overnight but improved significantly by the evening of July 4th. Assessment: Febrile viral illness, likely a cold or COVID given concurrent community spread. Good response to Tylenol and adequate fluid intake were reassuring signs. Plan: COVID testing suggested if a test was available at home. Tylenol as needed for fever. Monitor overnight and follow-up check-in the next morning. Follow-up confirmed significant improvement by July 4th evening. Medications: - Acetaminophen (Tylenol) age-appropriate, OTC (new) Key clinical quotes: "Some Covid picking up, if you have a test at home, you might want to check that" "Let's see how tonight goes and check in tomorrow morning." "Breathing ok, taking fluids ok? Temp respond to Tylenol?" Source: Spruce conversation t_27C02FVS44O00