Secure Message Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-02-23 Encounter: Spruce text message CC: Leg pain and limp with reluctance to walk. HPI: Jack woke up complaining his leg hurt and did not want to walk on it, though he chose to go to school. He played in gym but reported worsening pain by the time parent was notified. No fever reported at time of initial contact. No clear traumatic event described, though toddler's fracture was considered. Assessment: Dr. Hobbs considered two main diagnoses: transient synovitis (very common after a cold) and toddler's fracture (minor bone injury after minor trauma). Both are managed similarly with ibuprofen initially. Imaging deferred pending clinical response. Fever would be a critical red flag warranting urgent reassessment. Plan: Ibuprofen for pain. Monitor over the day and next day. If fever develops, contact Dr. Hobbs immediately. No imaging at this time. Follow-up on 2/26 — Jack reported his leg was 'fixed.' Medications: - Ibuprofen OTC, dose not specified Key clinical quotes: "Synovitis is super common, especially after a cold. Also, guys his age can have a toddlers fracture which is a minor injury to the bone after a minor trauma that can cause pain and limp." "Ibuprofen first and let me know how today and tomorrow go. If he has any fever, I want to know about that asap" Source: Spruce conversation t_226ST10QO3800