Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-10-13 Encounter: Photo review (otoscope images sent by parent via Spruce text message) CC: Ear pain starting the night before, worsening overnight; painful to sleep on affected side. HPI: Penelope, age approximately 8, complained of ear pain the prior evening and woke crying because it hurt to sleep on that side. She attended school the following day, and symptoms persisted through the day — she reported the ear felt plugged and hurt all day. Outer ear was extremely tender to touch. She had a runny nose but no fever. She had last swum at a birthday party approximately two weeks prior. Photos from a bebird otoscope were reviewed. No ear drainage reported. Assessment: External otitis (swimmer's ear) based on extreme tenderness to touch of the outer ear, irritated ear canal on photo review, and lack of fever or nasal congestion suggesting middle ear infection. Recent swim history (though 2 weeks prior) noted as a possible contributing factor though considered too remote. Plan: Prescription medication sent to CVS Excelsior for treatment of external ear infection. Weight and medication allergies confirmed prior to prescribing. Medications: - (Prescription sent — specific medication not documented in Spruce) Key clinical quotes: "that sounds like swimmer's ear more than a middle ear infection" "her canal is very irritated, has she been swimming at all?" "ok, let me get some meds sent in for her so she can feel better and you can all sleep" Source: Spruce conversation t_27C02FVS44O00