[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] so i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain . [patient] mm-hmm . [doctor] so logan , what happened to your back ? [patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy . [doctor] okay ... and did you strain your back , did something- [patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning . [doctor] okay , all right . [doctor] and is it your lower back , your upper back ? [patient] my lower back . [doctor] your lower back , okay . and what- what have you taken for the pain ? [patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help . [doctor] okay . and um ... do you have any numbing or tingling in your legs ? [patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away . [doctor] okay , and is there a position that you feel better in ? [patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ? [doctor] okay , all right . [doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk- [patient] mm-hmm . [doctor] . about today . were you able to take any vacations over the summer ? [patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends . [doctor] okay , well i'm glad to hear that . [doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... [patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . [patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating . [doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? [patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part . [doctor] okay , and you're you're taking your medication ? [patient] yes , i am . [doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? [patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay . [doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . [doctor] have you had any other symptoms , chest pain , nausea or vomiting- [patient] no . [doctor] . fever , chills ? [patient] no . no none whatsoever . [doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon ? show me the blood pressure . [doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- [patient] mm-hmm . [doctor] . blood pressure go up . let's look at the readings . [doctor] hey dragon ? show me the blood pressure readings . [doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . [patient] mm-hmm . [doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? [patient] sure . [doctor] and kick against my hands . [doctor] okay , good . all right . [doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . [patient] mm-hmm . [doctor] on your heart exam . which you've had in the past . [patient] mm-hmm . [doctor] so that sounds stable to me . [doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [patient] mm-hmm . [doctor] hey dragon ? show me the diabetes labs . [doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [patient] sure . [doctor] hey dragon ? show me the back x-ray . [doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [patient] mm-hmm . [doctor] . the history , okay ? [patient] mm-hmm . [doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . [doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [patient] mm-hmm . [doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- [patient] mm-hmm . [doctor] . and see how you do , okay ? [patient] you got it . [doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? [patient] mm-hmm . [doctor] hey dragon ? order a hemoglobin a1c . [doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . [patient] mm-hmm . [doctor] does that sound okay ? i think we need to get it under better control . [patient] no that's fine . i agree . [doctor] hey dragon ? order lisinopril 20 mg daily . [doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... [patient] mm-hmm . [doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ? [patient] mm-hmm . [doctor] do you have any questions logan ? [patient] not at this point . [doctor] okay . all right . [doctor] so the nurse will come in to help you get checked out , okay ? [patient] you got it . [doctor] hey dragon ? finalize the note .
ASSESSMENT AND PLAN

Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain.
 
 Lumbar strain.
 • Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable.
 • Medical Treatment: Initiate meloxicam 15 mg once a day.
 • Specialist Referrals: Referral to physical therapy.
 • Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity.
 
 Diabetes type 2.
 • Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately.
 • Additional Testing: Repeat hemoglobin A1c in 6 months.
 • Medical Treatment: Increase metformin to 1000 mg twice a day.
 
 Hypertension.
 • Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today.
 • Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day.
 
 Osteoarthritis.
 • Medical Reasoning: This is mostly well controlled.
 • Medical Treatment: Continue to monitor the knee. No further work up is needed at this time.
 
 