Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-10-16 Encounter: Spruce text message CC: Nagging cough for approximately 10 days, worse at night and in the morning. HPI: Penelope, age 7, shared a similar symptom profile with her brother Hendricks — persistent cough for approximately 10 days, worse at night and in the early morning. No fever. No runny nose mentioned specifically for her. Parents had been giving occasional nebulizer treatments. Assessment: Prolonged viral cough with nocturnal predominance consistent with post-viral reactive airway disease. Plan: Increase albuterol to 2-3 times daily. Add budesonide nebulizer twice daily. Medications: - Albuterol nebulizer, 2-3x/day - Budesonide nebulizer, twice daily Key clinical quotes: "I'd do the albuterol regularly 2-3 times a day and the budesonide 2x a day" Source: Spruce conversation t_27C02FVS44O00