[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 .

Medical orders:
description: hemoglobin a1c couple months
order_type: lab
reason: type 2 diabetes
description: lisinopril 20 milligrams once a day
order_type: medication
reason: congestive heart failure
description: see you again couple weeks
order_type: followup
description: meloxicam 15 milligrams once a day
order_type: medication
reason: acute lumbar , um , strain
description: metformin 1,000 milligrams twice daily
order_type: medication
reason: type 2 diabetes