DIALOGUE

[doctor] hi , james , how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you , too . 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] james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain .
[patient] mm-hmm .
[doctor] so , james , what happened to your back ?
[patient] uh , i was golfing and i hurt my back when i went for my backswing .
[doctor] okay . and did you feel a pop or a strain immediately or ?
[patient] i f- felt the pop , and i immediately had to hit the ground . i had to just try and do anything to loosen up my back .
[doctor] okay . and how long ago did this happen ?
[patient] this was saturday morning .
[doctor] okay . so , about four days ago ?
[patient] mm-hmm .
[doctor] okay . um , and what have you taken for the pain ?
[patient] uh , i took some tylenol . i took some ibuprofen .
[doctor] mm-hmm .
[patient] i tried ice . i tried heat , but nothing really worked .
[doctor] okay . and , h- how are you feeling now ? are you still in the same amount of pain ?
[patient] uh , by monday morning , it loosened up a little bit , but it's still pretty sore .
[doctor] okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ?
[patient] uh , i actually felt , um ... i had a struggle in my right foot like dropped foot . i had some struggling with my right leg . i felt that for a while , and it got a little bit better this morning but not much .
[doctor] okay . all right . um , so , are you ... how are you doing walking around ?
[patient] uh , uh , uh , i'm , i'm not going anywhere fast or doing anything strenuous but i can walk around a little bit .
[doctor] uh- .
[patient] not too fast .
[doctor] all right . okay . um , and any history with your back in the past ?
[patient] i actually had surgery about 10 years ago on my lower back .
[doctor] okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while .
[patient] mm-hmm .
[doctor] how are you doing with your diet ?
[patient] um , been pretty good t- taking my medications , watching my diet , trying to , uh , trying to exercise regularly , too .
[doctor] okay . so , you're avoiding the salty foods like we had talked about ?
[patient] yes .
[doctor] okay . and any weight gain or swelling in your legs recently ?
[patient] a little bit of weight gain over the summer but nothing , nothing too radical , nothing more than five pounds .
[doctor] okay . all right . and any problems laying flat while you go to bed ?
[patient] no .
[doctor] okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth .
[patient] yeah .
[doctor] jelly beans ?
[patient] i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it .
[doctor] okay . all right . um , and you're watching your blood sugars at home ?
[patient] mm-hmm . i monitor it regularly . not always, i can forget, , but i'm pretty good about my measuring it .
[doctor] okay . and you are still on your metformin ?
[patient] yes .
[doctor] okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in .
[patient] mm-hmm .
[doctor] i know that you were endorsing the back pain-
[patient] mm-hmm .
[doctor] . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot .
[patient] no .
[doctor] okay . um , so , i wan na go ahead and move on to a physical exam , okay ?
[patient] mm-hmm .
[doctor] hey , dragon , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good .
[patient] good .
[doctor] okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ?
[patient] mm-hmm .
[doctor] lean up . okay . all right . so , on your physical exam , everything seems fine .
[patient] good .
[doctor] on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past-
[patient] mm-hmm .
[doctor] . so that's stable .
[patient] okay .
[doctor] on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine-
[patient] mm-hmm .
[doctor] at the level of l5 .
[patient] okay .
[doctor] you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left .
[doctor] so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ?
[patient] okay , sure .
[doctor] hey , dragon , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ?
[doctor] hey , dragon , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ?
[patient] okay .
[doctor] um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain .
[patient] mm-hmm .
[doctor] and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri-
[patient] mm-hmm .
[doctor] . just to make sure that you do n't have any disc herniation or anything like that , okay ?
[patient] that's fine .
[doctor] how does that sound ?
[patient] no problem .
[doctor] hey , dragon , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily-
[patient] mm-hmm .
[doctor] . and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months .
[patient] okay .
[doctor] all right ? hey , dragon , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill-
[patient] actually , i-
[doctor] of the lisinopril ?
[patient] actually , i do .
[doctor] okay . hey , dragon , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ?
[patient] that's fine .
[doctor] um , any questions ?
[patient] not at this point .
[doctor] okay . hey , dragon , finalize the note .

CLINICAL NOTE

CHIEF COMPLAINT

Back pain.

HISTORY OF PRESENT ILLNESS

James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.

The patient states he was golfing and hurt his back. This happened approximately 4 days ago when he felt a pop in his back. The patient notes that he immediately hit the ground trying to loosen up his back. He reports taking some Tylenol, ibuprofen, and using ice and heat which did not relieve the pain. By Monday morning it loosened up a little bit, but it is still pretty sore. He had some right lower extremity weakness and some drop foot that he felt that for a while, and it got a little better this morning but not much. He had surgery about 10 years ago in his lower back.

Regarding his congestive heart failure, he has been watching his diet and trying to exercise regularly. He is avoiding the salty foods and has been compliant with medications. He has gained a little weight over the summer but nothing more than 5 pounds. He has no problems lying flat to go to bed.

Regarding his diabetes, he is watching his blood sugars at home, not always consistently. He is still on his metformin.

REVIEW OF SYSTEMS

 Constitutional: Denies weight loss. Endorses weight gain.
 Musculoskeletal: Endorses back pain. Endorses right leg weakness and drop foot.

PHYSICAL EXAMINATION

 Cardiovascular: Grade 2/6 systolic ejection murmur, stable.
 Musculoskeletal: Examination of his back reveals pain to palpation at L5. Decreased range of motion with flexion and extension. Positive straight leg raise. Strength is 4/5 on the right and 5/5 on the left.

Results:

X-ray lumbar spine, ordered and obtained in the office today, is unremarkable with good bony alignment.

Hemoglobin A1c is elevated at 8.

ASSESSMENT AND PLAN

James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.

Acute lumbar strain.
 Medical Reasoning: The patient reports feeling a 'pop' and immediate pain while golfing approximately 4 days ago. He has tried Tylenol and ibuprofen without significant relief.
 Additional Testing: If he continues to have pain, we will obtain an MRI for further evaluation.
 Medical Treatment: Initiate meloxicam 15 mg once daily.
 Specialist Referrals: We will refer him to physical therapy to work on strengthening the area.

Diabetes type 2.
 Medical Reasoning: He has been compliant with metformin and dietary modifications, but his recent hemoglobin A1c was 8.
 Additional Testing: Repeat hemoglobin A1c in a couple of months.
 Medical Treatment: Increase metformin to 1000 mg twice daily.

Congestive heart failure.
 Medical Reasoning: He is doing well from this standpoint. He has been compliant with his medications, dietary modifications, and regular physical activity.
 Medical Treatment: Continue lisinopril 20 mg once daily and Lasix. Lisinopril was refilled today.

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

INSTRUCTIONS

The patient will follow-up in 2 weeks.