[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 .

Medical orders:
description: meloxicam 15 milligrams once a day
order_type: medication
reason: back pain
description: lisinopril 10 milligrams po daily
order_type: medication
reason: hypertension