Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-08-27 Encounter: Spruce text message CC: Upset stomach and headache starting around noon, following similar illness in parent over 48 hours. HPI: Penelope, age 7 (born 08/28/2017), developed an upset stomach and headache starting around noon on 2024-08-27. Her parent Courtney had had an upset stomach, severe headache, shoulder soreness, and sinus pressure over the prior 48 hours. Penelope had no cough or sore throat. Ibuprofen was given at 2 PM with temporary improvement but symptoms returned. No fever reported. Assessment: Likely enterovirus infection, which characteristically causes gastrointestinal symptoms and significant headache and can spread through households. Plan: Ibuprofen for headache. Keep cool and well hydrated. Monitor for worsening. Medications: - Ibuprofen age-appropriate, OTC (new) Key clinical quotes: "It's probably from a virus called enterovirus" "Can give stomach symptoms and and a very bad headache" "Ibuprofen is best for the headache. Stay cool and hydrated." Source: Spruce conversation t_27C02FVS44O00