Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-01-05 Encounter: Spruce text message CC: Dry cough starting in the middle of the night, with runny nose, rosy cheeks, watery eyes, and mild fever. HPI: Malcolm, age approximately 3.5, developed a dry cough in the middle of the night. By the following day he had rosy cheeks, a minor runny nose, watery eyes, and a slight temperature. He slept approximately 2 hours later than normal. By January 6th, he had developed wheezier, heavier breathing though the cough had improved, and he remained in a good mood with good energy. A low-grade fever returned on January 6th evening. Albuterol nebulizer was started at home. Assessment: Viral upper respiratory illness with reactive airway component; wheeze and heavier breathing on day 2 warranted closer attention, though good mood and energy were reassuring. Monitor for increasing fever, worsening breathing, or persistent lethargy. Plan: Albuterol nebulizer as needed overnight and repeated as symptoms dictated. Monitor for worsening fever, increased work of breathing, or worsening lethargy. Continue nebulizer therapy. Thermometer link shared. Medications: - Albuterol nebulizer, as needed overnight (new) Key clinical quotes: "It should. You can repeat it overnight if needed" "I love great mood and energy!" "if his fever is increasing, if he breathing is worsening, if he's getting more consistently lethargic or anything else that worries you" Source: Spruce conversation t_27C02FVS44O00