[doctor] hi , cheryl . how are you ?
[patient] i'm doing well . how are you ?
[doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you .
[patient] okay .
[doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents today with back pain . cheryl , what happened to your back ?
[patient] so i've been walking a lot lately . i've been walking to ... 30 minutes to an hour or so a day . and all of a sudden , um , when i was walking , my , um , back just kind of seized up on me . and i do n't really know what it was . maybe i was going a little bit faster . but it just all kind of clenched .
[doctor] okay . so you felt like , maybe like a spasm or something like that ?
[patient] yeah .
[doctor] okay . and how many days ago was that ?
[patient] that was about six days ago now .
[doctor] okay . and what have you taken for the pain ?
[patient] i've been taking ibuprofen . um , and then i've been putting some heat on it . but it's still pretty stiff .
[doctor] okay . all right . um , and did you have any trauma before that happened ? were you doing anything strenuous like crossfit or lifting boxes or anything like that before you went for , for the walk ?
[patient] i have been lifting more , um , probably around three times a week . so i do n't know if it was because i was doing deadlifts that day and then walked .
[doctor] okay .
[patient] um , maybe i was using my back more than my legs .
[doctor] okay . all right . and was it any particular area in your back ? was it the lower back ?
[patient] yeah , it was .
[doctor] okay . on one side versus the other ?
[patient] um , kind of both equally .
[doctor] okay . all right . and any numbing or tingling in your legs or your feet ?
[patient] no , i have n't felt anything like that .
[doctor] okay . any weakness in your lower extremities ?
[patient] no .
[doctor] okay . all right .
and then in terms of your blood pressure , how are you doing ?
[patient] so i got that cuff that you suggested the ... our ... the last visit , and i've been doing readings at home . and that's been looking great , too . i've been watching my diet . again , my boyfriend's been great and dieting with me so i do n't have to do it alone . and everything's been good .
[doctor] okay . excellent . and you're taking the lisinopril ?
[patient] yes .
[doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ?
[patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies .
[doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you .
[patient] okay .
[doctor] okay ? hey , Sarah , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ?
[patient] okay .
[doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ?
[patient] okay .
[doctor] we did an x-ray before you saw me , so let's look at that . hey , Sarah , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ?
[patient] hmm .
[doctor] hey , Sarah , show me the labs . and your labs that we did before you came in all look great . there's no elevated white blood cell count . there's no signs of infection . again , those are all really good . okay ? so let me go over with you about my assessment and my plan for you . so for your first problem , this back pain , i think you have a lumbar strain , and , you know , that might've happened , you know , lifting something or exercising . and so what i want to do is prescribe meloxicam , 15 milligrams once a day . uh , i want you ... you can ice the area , and you can also apply heat sometimes as well . um , you know , i'm going to refer you to physical therapy just to do some strengthening exercises of your back , um , because i do want you to continue to be able to work out and exercise . okay ?
[patient] okay .
[doctor] and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ?
[patient] okay .
[doctor] do you need a refill of the lisinopril ?
[patient] yes , i do , actually .
[doctor] okay . hey , Sarah ? order lisinopril 10 milligrams po daily . okay . uh , so the nurse will be in soon , and she'll get you checked out . okay ?
[patient] okay .
[doctor] all right . hey , Sarah ? finalize the note .
CHIEF COMPLAINT

Back pain.

HISTORY OF PRESENT ILLNESS

Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.

The patient reports she has been walking a lot lately, 30 minutes to an hour or so a day. While walking 6 days ago, she felt her back seize up on her. She is not sure what caused it but thinks she was walking a little faster than usual. She describes the sensation as a spasm. She has been taking ibuprofen and using heat on it but it is still pretty stiff. She denies any known trauma or injury to her back. She notes she has been weightlifting around 3 times a week. She did do deadlifts that day before her walk and thinks she may have been using her back more than her legs to lift. She locates the pain in her mid lower back. She denies any lower extremity numbness, tingling, and weakness.

Regarding her hypertension, she states she has been doing readings at home and that has been looking great. She has been watching her diet which has helped. She is taking lisinopril.

The patient endorses nasal congestion, which she attributes to her seasonal allergies.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses nasal congestion from seasonal allergies.
• Musculoskeletal: Endorses bilateral low back pain and stiffness.
• Neurological: Denies numbness.

PHYSICAL EXAMINATION

• Cardiovascular: Slight 2/6 systolic ejection murmur, stable.
• Musculoskeletal: Pain to palpation along the right lateral aspect of her lumbar spine. Pain with flexion and extension. Negative straight leg raise.

RESULTS

Back x-ray reveals good bony alignment with no obvious fracture.

Labs: All within normal limits.

ASSESSMENT AND PLAN

Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.

Back pain.
• Medical Reasoning: She experienced a spasm-like pain in her back while walking approximately 6 days ago. She has also been lifting weights recently. Her lumbar spine x-ray was unremarkable and her recent labs were normal. I believe she has a lumbar strain.
• Medical Treatment: We will initiate meloxicam 15 mg once daily.
• Specialist Referrals: We will refer her to physical therapy to work on strengthening exercises.
• Patient Education and Counseling: She may apply ice and heat to the area.

Hypertension.
• Medical Reasoning: This is well controlled with lisinopril and dietary modifications based on home monitoring.
• Medical Treatment: She will continue lisinopril 10 mg daily. This was refilled today.
• Patient Education and Counseling: I encouraged her to continue with home monitoring and report any elevated blood pressures to me.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
