Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-07-22 Encounter: Phone Visit CC: Severe intermittent abdominal pain with diarrhea for 6 days, walking bent over. HPI: Jack (age 4) presented with doubled-over abdominal pain, excessive sweating, and ongoing loose stools for approximately 6 days (in the context of the recent HFM illness). Pain came and went and was worst around bowel movements or when he felt the urge to go. He had two accidents at home on 7/23. He was eating minimally (bananas, bread, some apple juice and water) and remained thirsty. Two children he spent time with on Monday were later confirmed to have strep. No fever. Strep was assessed as unlikely given symptom pattern. Assessment: Dr. Hobbs called the parent after the AI assistant flagged the severity of Jack's presentation. He assessed the pattern (crampy pain worst around bowel movements, soft stools in good amounts) as consistent with a viral gastroenteritis/enteritis and post-infectious gut irritability rather than a surgical emergency. Dehydration was noted as a potential contributor to pain. Strep exposure was noted but strep was not felt to explain the current symptoms. Plan: Phone call conducted. No Miralax given active loose stools in good amounts. Push fluids and light diet (bananas, bread, water). Distraction/screen time for comfort. Monitor for worsening, inability to walk, fever, or blood in stool. Post-illness lingering GI symptoms validated as normal on 8/5 follow-up. Key clinical quotes: "Waves of campy pain are would we would expect" "For sure can be. And that could make him more constipated." "that stinks, he's not showing symptoms of strep right now" Source: Spruce conversation t_226ST10QO3800