General Intake - Sleep Adult

Subjective:
Chief Complaint:
Chronic lower back pain and depression follow-up

History of Present Illness:
The patient, a male, presents with chronic lower back pain and depression. He reports persistent chronic lower back pain occurring throughout the day, with worsening symptoms in the mornings and after prolonged sitting. The pain has led to poor sleep quality. He describes a depressed mood with anhedonia and social withdrawal, rarely leaving the house except when necessary. He feels overwhelmed by the pain and its impact on his daily life. He denies active suicidal ideation but acknowledges passive thoughts of not wanting to wake up due to fatigue and emotional exhaustion.

Current Medications:
The patient has no prior use of serotonin-norepinephrine reuptake inhibitors or similar medications.

Objective:
Vital Signs:
Patient Health Questionnaire-9 score was 18, indicating moderate to severe depression.

Investigations:
Lumbar spine magnetic resonance imaging revealed mild degenerative disc disease without surgical indication.

Assessment:
Problem:
1. Chronic lower back pain (724.2)
2. Moderate to severe depression (296.22)

Plan:
I have initiated duloxetine at a low dose to target both mood symptoms and neuropathic pain. I have referred Mr. Carter to the behavioral health team for cognitive behavioral therapy to help manage his chronic pain and depression. He will continue physical therapy for his lower back pain. Additionally, I have prescribed a short-term muscle relaxant to assist with back pain management. Follow-up appointments are scheduled every 2 to 3 weeks to monitor his progress and make any necessary adjustments to the treatment plan.

Surgery Discussion:
After reviewing your lumbar spine MRI, there is no indication for surgery at this time. Therefore, we recommend continuing with conservative management, which includes physical therapy and medication to help manage your symptoms. Surgery is not advised unless your condition changes or does not improve with these treatments.