General Intake with Comprehensive Neuro Exam

Subjective:
Chief Complaint:
Chronic lower back pain and depression

History of Present Illness:
Mr. Carter presents for evaluation of chronic lower back pain and associated depressive symptoms. He reports that his lower back pain is persistent, present throughout the day, and exacerbated in the mornings and after prolonged sitting. The pain has negatively impacted his sleep quality. Mr. Carter describes a significant decline in mood, characterized by pervasive low mood, anhedonia, and social withdrawal, stating that he rarely leaves the house unless necessary. He denies active suicidal ideation but acknowledges passive thoughts of not wanting to wake up due to fatigue and emotional exhaustion. He identifies a cyclical relationship between his chronic pain and depressive symptoms, with each exacerbating the other. There is no mention of new neurological deficits, headaches, tremors, sensory changes, or cognitive impairment. Previous lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without surgical indication. No prior use of serotonin-norepinephrine reuptake inhibitors is reported. Mr. Carter has not indicated any prior engagement with behavioral health interventions for these symptoms.

Past Medical History:
No significant findings.

Past Surgical History:
No surgical history provided.

Current Medications:
No current medications reported. No prior use of medications like duloxetine.

Allergies:
No allergies reported.

Family History:
No family history of neurological or hereditary conditions provided.

Social History:
Mr. Carter reports significant social withdrawal, rarely leaving the house unless necessary. No information provided regarding tobacco or alcohol use, occupation, or exposure to toxins.

The Review of Systems:
- Neurological – No headaches, dizziness, or weakness. No active thoughts of self-harm.
- Constitutional – No fever, chills, or weight loss
- Eyes – No visual disturbances or eye pain
- ENT – No hearing changes or tinnitus
- Cardiovascular – No chest pain or syncope
- Respiratory – No shortness of breath
- Gastrointestinal – No nausea or bowel changes
- Musculoskeletal – No muscle or joint pain

Objective:
Vital Signs:
No vital signs provided.

Physical Examination:
**General Examination:**

- General Appearance – Patient is in no acute distress.
- Respiratory System – Lungs clear to auscultation bilaterally.
- Cardiovascular – Regular rate and rhythm
- Abdomen – Non-tender, no masses

**Neurological Exam:**

- Mental Status – Alert and oriented to person, place, and time
- Cranial Nerves II-XII – Intact
- Motor – 5/5 strength in all extremities
- Reflexes – DTRs +2/4 and symmetric
- Sensory – Intact to light touch and pinprick
- Coordination – No dysmetria on finger-to-nose test
- Gait & Station – Stable gait, able to stand without assistance

Test Results:
Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without surgical indication. Patient Health Questionnaire-9 score is 18, indicating moderate to severe depression.

Assessment:
Problem:
Mr. Carter presents with chronic lower back pain and associated moderate to severe depressive symptoms.

Differential Diagnosis:
1. Intervertebral disc disorders w radiculopathy, lumbar region (M51.16)
2. Major depressive disorder, recurrent, moderate (F33.1)
3. Chronic pain syndrome (G89.4)

Plan:
- Other low back pain (M54.59): Persistent, daily lower back pain, worse in the mornings and after prolonged sitting, negatively impacting sleep quality. Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without surgical indication.
Plan:
• Continue physical therapy for lumbar spine stabilization and mobility
• Consider short-term muscle relaxant for symptomatic relief
• Scheduled follow-up in 2–3 weeks to monitor pain control and functional status

- Major depressive disorder, recurrent, moderate (F33.1): Significant decline in mood, anhedonia, social withdrawal, and PHQ-9 score of 18. Passive thoughts of death without active suicidal ideation. Depression is exacerbated by chronic pain.
Plan:
• Initiate duloxetine at a low dose, titrating as tolerated, to address both depressive symptoms and neuropathic pain
• Educated Mr. Carter regarding potential side effects of duloxetine, including gastrointestinal upset, dizziness, and drowsiness
• Referral to behavioral health team for cognitive behavioral therapy to address mood and pain coping strategies
• Scheduled follow-up in 2–3 weeks for reassessment of mood, safety, and medication tolerability
• Provided reassurance and emphasized collaborative approach to management

Assessment and Plan:
Impression:
Mr. Carter exhibits persistent chronic lower back pain with associated moderate to severe depressive symptoms, as evidenced by a Patient Health Questionnaire-9 score of 18. Lumbar spine magnetic resonance imaging reveals mild degenerative disc disease without surgical indication. He denies new neurological deficits, headaches, tremors, sensory changes, or cognitive impairment. He reports passive thoughts of death but denies active suicidal ideation.

- Other low back pain (M54.59): Persistent, daily lower back pain, worse in the mornings and after prolonged sitting, negatively impacting sleep quality. Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without surgical indication.
Plan:
• Continue physical therapy for lumbar spine stabilization and mobility
• Consider short-term muscle relaxant for symptomatic relief
• Scheduled follow-up in 2–3 weeks to monitor pain control and functional status

- Major depressive disorder, recurrent, moderate (F33.1): Significant decline in mood, anhedonia, social withdrawal, and PHQ-9 score of 18. Passive thoughts of death without active suicidal ideation. Depression is exacerbated by chronic pain.
Plan:
• Initiate duloxetine at a low dose, titrating as tolerated, to address both depressive symptoms and neuropathic pain
• Educated Mr. Carter regarding potential side effects of duloxetine, including gastrointestinal upset, dizziness, and drowsiness
• Referral to behavioral health team for cognitive behavioral therapy to address mood and pain coping strategies
• Scheduled follow-up in 2–3 weeks for reassessment of mood, safety, and medication tolerability
• Provided reassurance and emphasized collaborative approach to management