[doctor] hi , bryan . how are you ? [patient] i'm doing well . i'm a little sore . [doctor] yeah ? [patient] yeah . [doctor] all right , well , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] that's fine . [doctor] so bryan is a 55-year-old male with a past medical history significant for prior discectomy , who presents with back pain . so , bryan , what happened to your back ? [patient] you ... my wife made me push a , uh , refrigerator out through the other room , and when i was helping to move it , i felt something in my back on the lower right side . [doctor] okay , on the lower right side of this back ? [patient] yes . [doctor] okay . those wives , always making you do stuff . [patient] yes .  [doctor] and what day did this happen on ? how long ago ? [patient] uh , this was about five days ago . [doctor] five days ago . [patient] and , you know , i have that history of discectomy . [doctor] yeah . [patient] and i'm just worried that something happened . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] um , i have , uh , been taking ibuprofen . uh , and i tried once tylenol and ibuprofen at the same time , and that gave me some relief . [doctor] okay . all right . and have you had any symptoms like pain in your legs or numbing or tingling ? [patient] um , no , nothing significant like that . [doctor] okay , just the pain in your back . [patient] just the pain in the back . it hurts to bend over . [doctor] okay , and any problems with your bladder or your bowels ? [patient] no , no . [doctor] i know the nurse said to review a symptom sheet when you checked in . [patient] mm-hmm . [doctor] and i know that you were endorsing the back pain . any other symptoms ? chest pain ? shortness of breath ? abdominal pain ? [patient] no . [doctor] nausea ? vomiting ? [patient] no other symptoms . [doctor] okay . all right . well , let's go ahead and do a quick physical exam . hey , dragon , show me the vital signs . so your vital signs here in the office look really good . you do n't have a fever . your blood pressure's nice and controlled . so that ... that's good . i'm just gon na check out your back and your heart and your lungs , okay ? [patient] okay . [doctor] okay , so on physical examination , you know , your heart sounds great . there's ... it's a regular rate and rhythm . your lungs are nice and clear . on your back exam , you do have some pain to palpation of the right lumbar spine , uh , in the paraspinal muscles along with decreased flexion and extension of the back , and you have a positive straight leg on the right . or positive straight leg raise on the right , uh , but your strength is good bilaterally in your lower extremities . so that means that i think that you've injured your back . [patient] okay . [doctor] uh , but , you know , i think it's something that we can , we can fix , okay ? [patient] okay , you do n't think there's anything wrong with the ... where i had the surgery before . [doctor] i do n't think so . [patient] okay . [doctor] let's took at some of your results . hey , dragon , show me the back x-ray . so this is an x-ray of your lumbar spine . you know , there's good bony , bony alignment . i do n't see any fracture or anything like that . so that's a good sign . um , hey , dragon . show me the labs . and your labs here all look good , so i'm , i'm happy to see that . uh , so let's talk a little bit about my assessment and my plan for you , okay ? [patient] okay . [doctor] so i ... my assessment for your first problem , your back pain . i think you have a lumbar strain . i do n't think that anything else is going on , but i wan na go ahead and order an mri- [patient] okay . [doctor] just to be sure . [patient] okay . [doctor] okay ? and then i'm gon na prescribe you some meloxicam 15 milligrams once a day along with some ultram , 50 milligrams every four hours as needed , okay ? [patient] okay . [doctor] um , and then we'll go ahead and refer you to some physical therapy once we get the mri results back , okay ? [patient] should i continue to take the tylenol and the ibuprofen ? [doctor] you can stop the ibuprofen . [patient] okay . [doctor] you can take tylenol if you want . [patient] okay . [doctor] you know to call me if , if you need anything . [patient] okay . [doctor] okay ? [patient] okay . [doctor] any questions , uh , bryan ? [patient] no , no questions . [doctor] okay . hey , dragon , finalize the note .
ASSESSMENT AND PLAN

Bryan Smith is a 55-year-old male with a past medical history significant for prior discectomy, who presents with back pain.
 
 Lumbar strain.
 • Medical Reasoning: He reports right-sided low back after moving a refrigerator approximately 5 days ago. X-ray of his lumbar spine is unremarkable. I do not believe this is related to his previous discectomy.
 • Additional Testing: We will order a MRI of the lumbar spine for further evaluation.
 • Medical Treatment: Initiate meloxicam 15 mg once daily, as well as Ultram 50 mg every 4 hours as needed.
 • Specialist Referrals: We will refer him to physical therapy to be started after we get his MRI results back.
 • Patient Education and Counseling: I advised the patient to discontinue the use of ibuprofen, but he may continue using Tylenol if he wishes.
 
 