[doctor] good morning noah tell me a little bit about why you are here today
[patient] hi document i'm i'm just had you know the back pain you know and i've i've had it for you know about a week and
[doctor] oh
[patient] you know i mean i tried some you know i mean medications but you know some over the counter stuff but it does n't go away
[doctor] okay can you tell me a little bit more about it how did it start or how did it do you remember injuring yourself
[patient] no not really i mean i was just like you know i guess i one day i mean i just twisted you know on my left and maybe i mean i might have picked something up
[doctor] okay
[patient] so i mean at that time i mean there was this pain but i you know it went away you know and i thought that was you know that was you know the end of it but you know i mean after you know a few hours you know it's it kinda it came back
[doctor] okay
[patient] it's been there since then you know
[doctor] okay and is it anywhere in specific is it in the middle of the back across the whole low back or on one side or the other
[patient] i think it's more towards you know right in the middle maybe on the lower side and nothing on the you know i mean it sometimes it goes back you know maybe having troubles with the left eye i suppose but i mean it's aggravated you know when i you know when i do some you know maybe i'm a sudden movement to the left
[doctor] okay and that's when you get the pain more maybe located in the center but it goes across to the little back and i on the left side and i also heard you say you know if you twist suddenly that makes it worse is that correct
[patient] it makes it worse it makes it worse i mean yeah
[doctor] now you know i was looking at your records and i know you have that history of diabetes and i have n't seen you a while for a follow-up for that how you've been feeling
[patient] i mean been okay i mean i take my meds
[doctor] okay
[patient] and i try to still have sugar but you know i mean i you know you know i mean whenever i get the chance i mean i you know i exercise but you know i mean that's about it
[doctor] okay so you're on
[patient] mm-hmm
[doctor] yeah i think i think you're on that metformin twice a day
[patient] yeah
[doctor] yeah okay
[patient] yes
[doctor] do you test your blood sugar at home in the mornings
[patient] yeah i mean i try to
[doctor] okay
[patient] most of the morning but sometimes i mean i go skiing yeah
[doctor] and how have those numbers been
[patient] they bumped towards i mean bit towards the higher side i mean i must have been
[doctor] okay
[patient] you know but
[doctor] well if
[patient] yeah
[doctor] yeah if i remember right your family do n't they own that that bakery down on the corner of main street and did n't they own that
[patient] yeah thank you
[doctor] and how do you do you stay away from those i i got ta be honest i love i love the cakes and donuts they make those are delicious
[patient] yeah i try to
[doctor] okay
[patient] but i mean you know they they you know i have to visit them and you know i end up you know i mean getting some stuff but it's not that much
[doctor] okay
[patient] but it's been i try to contain it you know
[doctor] well let me so we're gon na have to watch that and i'll come back and we'll talk a little bit about the diabetes but let's go ahead and do that i do n't wan na do a a a quick physical exam on you i'm gon na look in your eyes here and so let me quickly look in your ears
[patient] i see
[doctor] okay that looks good and any let me let me listen to your lungs okay your lungs are clear and your heart it's a regular rate and rhythm that's all good as we go through that now i want you to sit up here i'm gon na press down your back starting at the top and any pain up top no
[patient] no
[doctor] okay and then once i get down here and around that low back i wan na press in the center first does that cause you a lot of pain
[patient] yeah
[doctor] yeah okay
[patient] yeah that that's the spot
[doctor] okay and if i come over here to the right no
[patient] not that much you know
[doctor] okay so and then on the left hand side if i push down here kind of into your butt
[patient] yeah
[doctor] yeah okay
[patient] yeah
[doctor] lay back on the stretcher for me for a second i'm gon na go ahead and and lift your legs for me or i'm gon na go ahead and lift your legs for you just relax i'm gon na start here on the right side when i lift that right leg up does that cause you significant pain or any pain at all
[patient] a little a little bit
[doctor] okay let me come around let me lift up the left side if i lift that up does that cause
[patient] yeah yeah yeah that's that's
[doctor] yeah
[patient] still get tender yeah
[doctor] i can see that gritts on your face so okay that's good and you know as i look at your lower extremities there is no pain or numbness or tingling in your feet or anything like that
[patient] hmmm no
[doctor] okay okay so lem me talk a little bit about my impression and plan so for that low back pain i believe you have a musculoskeletal low back strain i'm going to order a low back x-ray so we'll order that and get that done as an outpatient i do n't expect to see anything significant but it's gon na tell me how those joint spaces look and if you know if we're dealing with any disk issue but that will be the start of it and i'm also gon na order some physical therapy two for two reasons to help with a little bit with the pain but also strengthen some of the muscles there in the back so those are the two things that we are gon na do now i want you to take take four hundred milligrams of ibuprofen you can take that occasionally with some tylenol when the pain gets more severe up to about three times a day i'm gon na also give you a prescription for some flexeril that's a muscle relaxant and i want you to take one of those once a day every evening but be careful if you're doing any strenuous or hazardous activities such as driving after you take those now for your diabetes my impression is that your diabetes is is under control i noticed that we do n't have n't had a a1c for almost five months so i'm also gon na order an a1c so we can find out where we are with that continue with your diet and exercise we know that's really important and then continue with your metformin i'm not gon na make any changes today but we'll go ahead and look at that once i get that results of that a1c do you have any questions for me
[patient] yeah can i still go to the bakery
[doctor] i would yes it's nice for you to go to the bakery but you ca n't have any donuts i'm no i you just really need to watch that intake of of anything that you might get at the at the bakery so just just be careful with those carbohydrates those sweets that you're taking as we go through your day it's occasional occasional one perfectly fine but on a routine basis we need to watch that
[patient] right and how soon should i you know check my blood sugars i mean what's a good you know
[doctor] yeah i that's a great question i'm really glad you asked that i would prefer that you're taking your blood pressure every morning the first thing you get up when you get up in the morning that's gon na give me a good idea and so if you can do that the first thing in the morning and keep a record of it you know i know your glucometer keeps a record of it but if you can write them down and once we get that a1c that's gon na give me a little more guidance on how to deal with your blood your diabetes
[patient] right do you think would i need to see you know a pain doctor or you know
[doctor] not yet let's let's get the that's a great question i may end up referring you to a a pain doctor for that low back pain but i really would like to start with some of the diagnostics first let's get an x-ray and if there is you know any question of that x-ray and the pain continues i'm gon na go ahead and maybe order a cat scan and then at that point in time we can refer you to a pain doctor if we're still having significant pain
[patient] sounds good
[doctor] okay thank you i'm gon na send my nursing to see you and we'll get you out the door
[patient] thank you
[doctor] take care
[patient] that one is a follow-up mm-hmm
CHIEF COMPLAINT

Back pain.

MEDICAL HISTORY

Patient reports history of diabetes.

SOCIAL HISTORY

The patient's family owns and runs a bakery.

MEDICATIONS

Patient reports taking metformin twice daily.

REVIEW OF SYSTEMS

Musculoskeletal: Reports back pain.
Neurological: Denies numbness or tingling in feet.

PHYSICAL EXAM

Eyes
- Examination: No redness, discharge, or icterus.

Ears, Nose, Mouth, and Throat
- Examination of Ears: Auditory canal and tympanic membranes are clear.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm.
Musculoskeletal
- Examination: No pain to palpation of the upper back. Pain to palpation of the midline of the lower back, especially on the left. No pain to palpation on the right lower back. Mildly positive straight leg rise on the right Positive straight leg rise on the left.

ASSESSMENT AND PLAN

1. Low back pain.
- Medical Reasoning: I believe he has a musculoskeletal low back strain. I do not expect to see anything significant on x-ray, but we will obtain one for further evaluation of any possible disc issues.
- Patient Education and Counseling: We discussed his diagnosis at length today. I explained that physical therapy can help with the pain, but also strengthen some of the muscles in the back. I explained that he needs to be careful while taking medications, such as an overuse of muscle relaxers if he is doing any strenuous or hazardous activities such as driving.
- Medical Treatment: Low back x-ray ordered. Referral to physical therapy provided. He will take 400 mg of ibuprofen up to 3 times per day. Tylenol can be used for severe pain. Prescription for Flexeril also provided.

2. Diabetes.
- Medical Reasoning: His diabetes is currently under control.
- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. I encouraged him to try an avoid foods high in sugar. He asked many questions and I feel he is confident in the plan at this point.
- Medical Treatment: Hemoglobin A1c ordered as he has not had an updated one in almost 5 months. He will continue with his diet and exercise. Continue current dose of metformin for the time being. The patient will be checking his blood sugar in the morning and will log this information for me.

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