[doctor] hi , john . how are you ? [patient] hey . well , relatively speaking , okay . good to see you . [doctor] good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . [patient] okay . [doctor] so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? [patient] uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned . [doctor] yeah . and so wh- what side of your back is it on ? [patient] uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back . [doctor] okay . and , um , how many days has this been going on for ? [patient] the last four days . [doctor] okay . and is ... is the pain coming and going ? [patient] um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad . [doctor] okay . and what have you taken for the pain ? [patient] tylenol , but it really does n't seem to help . [doctor] yeah . okay . and do you have any blood in your urine ? [patient] um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color . [doctor] okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? [patient] um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen . [doctor] okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . [patient] i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that . [doctor] okay , so no issues with the migraine ? [patient] none whatsoever . [doctor] okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . [patient] yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good . [doctor] okay . are you staying hydrated ? [patient] yes . [doctor] okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? [patient] i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago . [doctor] okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] sure . [doctor] okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . [patient] mm-hmm . [doctor] um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- [patient] mm-hmm . [doctor] . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? [patient] okay . [doctor] so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? [patient] mm-hmm . [doctor] and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? [patient] okay . [doctor] hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . [patient] yes , i am . [doctor] for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? [patient] actually , i do need a refill . [doctor] okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . [patient] perfect . [doctor] if your symptoms worsen , just give me a call , okay ? [patient] you got it . [doctor] take care . [patient] thank you . [doctor] hey ... hey , dragon ? finalize the note .
ASSESSMENT AND PLAN

Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with back pain.
 
 Kidney stones.
 • Medical Reasoning: He is experiencing pain in his back that is similar to his previous kidney stone pain. His recent abdominal x-ray demonstrates what appears to be a recurrent kidney stone.
 • Additional Testing: I have ordered a CT scan of the abdomen and pelvis without contrast.
 • Medical Treatment: We will start him on Ultram 50 mg as needed every 6 hours for pain.
 • Patient Education and Counseling: I advised the patient to stay well hydrated and to strain his urine.
 
 Migraines.
 • Medical Reasoning: He has been compliant with Imitrex and is doing well at this time.
 • Medical Treatment: Continue Imitrex.
 
 Reflux.
 • Medical Reasoning: This is typically well-controlled with dietary modifications.
 • Medical Treatment: Continue with Protonix 40 mg daily. A refill was provided.
 
 