[doctor] hello mrs. lee , i see you're here for back pain .
[patient] yes .
[doctor] hey dragon , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ?
[patient] yes . i was at a birthday party and it was surprise party . so we were all like crunched behind and hiding . and when the person came in we all jumped out , and then i fell down the little stair and i rammed my back into the railing of the s- , uh , staircase .
[doctor] so it was a surprise for you too ?
[patient] yes it was .
[doctor] very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ?
[patient] i think it was my motion-
[doctor] okay .
[patient] . of jumping up , or something .
[doctor] okay .
[patient] and maybe a twisting .
[doctor] okay . any pain shooting down your legs at all ?
[patient] no .
[doctor] is it on one side or the other of your back ?
[patient] um , it's more on the right .
[doctor] on the right . is there anything that makes it better or worse ?
[patient] uh , if i'm lying flat it hurts a little more , and any twisting motion for sure .
[doctor] okay . all right . and do you have any history or any back problems before ?
[patient] i did . i had a fusion done .
[doctor] okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey dragon , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ?
[patient] yes .
[doctor] okay . you can sit back down . if i lift your leg here , does that bother you ?
[patient] no .
[doctor] how 'bout when i lift this leg ?
[patient] no .
[doctor] any pain shooting down your legs when i do that ?
[patient] no .
[doctor] okay . and can you feel me touching down here .
[patient] yes .
[doctor] okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ?
[patient] just some ibuprofen .
[doctor] okay . and do you have any other , um , medical problems ?
[patient] um i take medication for anxiety .
[doctor] okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking .
[patient] okay .
[doctor] um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .
[patient] okay .
[doctor] does that sound good ?
[patient] it does .
[doctor] okay , dragon . hey dragon , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .
[patient] thank you .

Medical orders: