Other Template

Dr Shamoon's Template 3 (Clone) (Clone)

A professional Other template for healthcare professionals.

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Subjective:
1. Chronic low back pain: 
- Persistent, daily, worse AM/after prolonged sitting
- Sleep disturbed by pain
- No prior SNRI use
2. Depression: 
- Low mood, anhedonia, social withdrawal
- PHQ-9: 18 (mod-severe)
- No active suicidal ideation

Objective:
Physical Examination:
BP:  O2 sats:  HR: 
GEN: NAD
HEENT: 
CARDIO: 
RESP: 
ABDO: 
EXTREM: 
No specific physical findings documented.

Assessment and Plan:
1. Chronic low back pain (M54.5) (ddx: degenerative disc disease):
• Continue PT
• Consider short-term muscle relaxant
• No surgical indication on lumbar spine MRI
2. Depression (F32.A) (ddx: major depressive disorder):
• Start duloxetine low dose
• Refer behavioral health for CBT
• Schedule f/u 2-3 weeks

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