General Surgery Consult

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

PLAN: 
The physician has recommended starting a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), specifically duloxetine, to address both mood concerns and nerve-related pain. A referral has been made to the behavioral health team for cognitive behavioral therapy (CBT) to support the management of chronic pain and depression. Continuation of physical therapy has been advised, with consideration for adding a short-term muscle relaxant if needed. Follow-up appointments with Mr. Carter are planned every 2–3 weeks to monitor his progress and provide ongoing support.

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

Mr. Carter reports persistent lower back pain that has been present daily without improvement. He describes the pain as being worse in the mornings and after prolonged sitting. He also reports difficulty sleeping due to the pain. He acknowledges that the chronic pain has significantly impacted his mental health, creating a cycle where the pain exacerbates his depression and vice versa. Mr. Carter rarely leaves the house unless absolutely necessary, significantly impacting his social activities and daily functioning. Psychological review reveals low mood and loss of interest in activities. He denies active thoughts of self-harm.

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

On Exam:
Cardiovascular and respiratory exams are grossly normal.

Investigations:
Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.
Patient Health Questionnaire (PHQ-9) score: 18, indicating moderate to severe depression.

IMPRESSION AND PLAN:
Mr. Carter presents with chronic lower back pain and moderate to severe depression. His symptoms are persistent and have a significant impact on his daily functioning and mental health. MRI findings show mild degenerative disc disease without surgical indications. The plan includes starting duloxetine, referral to behavioral health for CBT, continuation of physical therapy, and consideration of a short-term muscle relaxant if needed. Regular follow-up every 2–3 weeks is planned to monitor progress and provide support.

Assessment:
Mr. Carter’s chronic lower back pain is likely multifactorial, with mild degenerative disc disease seen on MRI but no surgical indication. His depression is moderate to severe, as indicated by his PHQ-9 score and clinical interview. The interplay between chronic pain and depression is contributing to his overall impairment. Non-surgical management is appropriate at this time.

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): Start low-dose duloxetine, refer to behavioral health for CBT, monitor closely 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 with Mr. Carter are planned every 2–3 weeks to monitor his progress and provide ongoing support.

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