Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-03-27 Encounter: Spruce text message followed by in-person visit CC: Sore throat with pain on swallowing, progressing to low-grade fever and ear pain requiring an in-person visit. HPI: Miles came home from school with a sore throat on 2024-03-27. The sore throat was described as painful to talk and swallow, not scratchy, with no runny nose and no visible throat findings concerning to the parent initially. He had no history of frequent illness. A COVID test was negative. By the afternoon he developed a low-grade fever of 100°F. He denied hoarseness but reported pain in his throat and ears. Symptoms improved after ibuprofen and a nap, but overnight (into 2024-03-28) he had significant bilateral ear pain waking him from sleep, prompting an urgent in-person visit. Assessment: Initial presentation did not appear consistent with strep (no high fever, no classic exudate, improved with ibuprofen). However, overnight development of significant ear pain prompted an in-person evaluation. Following the in-person visit, amoxicillin was prescribed, indicating a diagnosis of otitis media (ear infection) was made. Plan: Day 1: Watch and wait, ibuprofen for fever and pain, parent to provide updates. Day 2 (2024-03-28): In-person visit at the clinic. Prescription sent for amoxicillin 800mg by mouth twice daily for 10 days (10ml of 400mg/5ml suspension). Ibuprofen also approved for concurrent use for pain. Parents counseled to watch for allergic reaction as this may have been Miles's first exposure to amoxicillin. Medications: - Amoxicillin 800mg (10ml of 400mg/5ml) by mouth twice daily for 10 days (new) - Ibuprofen standard dose, as needed (new) Key clinical quotes: "generally strep throat comes with a fever, headache, sometimes stomach ache and a very sore throat. kids with strep usually look pretty sick too." "I like the watch and see plan. Would you mind sending me another update later in the afternoon?" "800mg by mouth twice a day for 10 days total (10ml of 400mg/5ml of amoxicillin twice a day)" Source: Spruce conversation t_25GF4V55J8800