Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2025-05-10 Encounter: Spruce text message (with photo of location sent by parent) CC: Back and hip pain ongoing for approximately one year, worsening enough to prompt evaluation. HPI: Eamon reported back/hip pain localized to an area shown in a photo sent by the parent. He described it as hurting 'all the time' and stated it had been present for approximately one year, though he had not mentioned it at the February visit or at a Tria visit for Sever's disease diagnosis. Parent asked whether to come see Dr. Hobbs first or go directly to Tria. Dr. Hobbs assessed flexibility (toe-touch test), which parent reported was easy. No trial of ibuprofen or heat had been attempted. Assessment: Pain location most consistent with muscular irritation or lack of flexibility in the posterior chain. Flexibility was preserved (able to touch toes easily), making tight posterior chain less likely as primary etiology. Further information needed via response to ibuprofen or heat. Plan: Trial of ibuprofen and/or heat recommended to assess response and guide next steps. Medications: - Ibuprofen dose not specified (new) Key clinical quotes: "I suspect he has a tight posterior chain in his legs. How well can he touch his toes with his feet together and keep his knees straight?" "the location he's pointing too is most often related to muscular irritation or lack of flexibility in that part of his body" "That will help us know more about next steps" Source: Spruce conversation t_27GA7V0S3U800