Breast Cancer Consult

DIAGNOSIS: 
1. Other low back pain (M54.59)
2. Major depressive disorder, recurrent, moderate (F33.1)

PLAN: 
The plan includes initiating a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), specifically duloxetine, to target both mood symptoms and nerve-related pain. A referral has been made to the behavioral health team for cognitive behavioral therapy (CBT) to aid in managing chronic pain and depression. Continuation of physical therapy is recommended, with consideration for adding a short-term muscle relaxant if needed. Follow-up appointments are planned every 2–3 weeks to monitor the patient’s progress and provide ongoing support.

Thank you for referring Mr. Carter for chronic lower back pain and depression. 
He was examined on 2026-02-04.

Mr. Carter reports persistent lower back pain present daily without improvement. The pain is worse in the mornings and after prolonged sitting. He reports difficulty sleeping due to the pain. He describes feelings of low mood, loss of interest in activities, and social withdrawal. He notes the chronic pain has significantly impacted his mental health, creating a cycle where the pain worsens his depression and vice versa. He denies active thoughts of self-harm. Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention. His PHQ-9 score is 18, indicating moderate to severe depression. Mr. Carter has never taken medications like duloxetine before.

Past Medical History: 
Medications: Mr. Carter has never taken medications like duloxetine before.
Allergies: 

Investigations:
Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.

IMPRESSION AND PLAN:
Mr. Carter presents with chronic lower back pain and moderate to severe depression, as evidenced by his PHQ-9 score and clinical interview. Imaging demonstrates mild degenerative disc disease without surgical indications. The plan is to initiate duloxetine, refer to behavioral health for CBT, continue physical therapy, and consider a short-term muscle relaxant if needed. Follow-up is planned every 2–3 weeks.

Assessment:
Mr. Carter’s chronic lower back pain and depression are interrelated, with each exacerbating the other. Imaging does not support surgical intervention at this time. The treatment approach is multidisciplinary, targeting both pain and mood symptoms.

Plan and Recommendations: 
1. Other low back pain (M54.59): Continue physical therapy, consider short-term muscle relaxant if needed, no surgical intervention indicated.
2. Major depressive disorder, recurrent, moderate (F33.1): Initiate duloxetine, refer to behavioral health for CBT, monitor progress with follow-up every 2–3 weeks.

Surgery Discussion:
For mild degenerative disc disease, surgical intervention is not necessary. Non-surgical treatment options are available and may be sufficient to manage the condition effectively.

Follow-Up:
Follow-up appointments are planned every 2–3 weeks to monitor the patient’s progress and provide ongoing support.

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