[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 , dragon , 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 , dragon , 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 , dragon , 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 , dragon ? 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 , dragon ? finalize the note .
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.
 
 