Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-11-09 Encounter: Photo review (throat photo sent by parent) followed by in-person visit CC: Sore throat described as 'bubbly,' with ear and neck pain and refusal to eat or drink. HPI: Miles presented on 2025-11-09 with a sore throat he described as 'bubbly' and pain in his ears, consistent with prior episodic presentations. He also had neck pain described as needing to be 'cracked.' No fever was detected, no runny nose. His throat appeared pink on visual inspection. He was irritable and refusing to eat or drink, though some soup was given. A photo of his throat was sent to Dr. Hobbs for review. Overnight he stayed home from school the following day (2025-11-10) and was seen in-person at 10:30am. He still had no fever at follow-up but continued to complain of a sore throat. Assessment: Throat photo showed pharyngitis without classic strep findings (no red dots on palate, no white patches on tonsillar pillars). Symptoms were not classic for strep. However, given missed school and ongoing pain, an early in-person checkup was arranged. Following the in-person visit, penicillin was prescribed, suggesting strep pharyngitis was confirmed or clinically diagnosed at that time. Plan: Initial plan was watchful waiting with instructions to return if fever developed or pain worsened. In-person visit on 2025-11-10 at 10:30am. Prescription sent for penicillin 500mg tablets: 1 tablet three times daily OR 1.5 tablets twice daily for 10 days. Medications: - Penicillin 500mg: 1 tablet three times daily or 1.5 tablets twice daily for 10 days (new) Key clinical quotes: "so he has pharyngitis (sore throat) and doesn't have the bad signs for strep - red dots on the roof of his mouth, white patches on the sides of his throat" "The symptoms he's having aren't classic for strep and his throat also isn't classic for it. If he gets a fever, the pain is worsening, let's reevaluate." "If he ends up missing school, we could just do his checkup early and also check him out" Source: Spruce conversation t_25GF4V55J8800