General Surgery Follow up

Interval Update:
Mr. Carter reports no improvement in his chronic lower back pain since the last visit. The pain remains constant throughout the day, is worse in the mornings and after prolonged sitting, and has disrupted his sleep. He expresses persistent low mood, decreased interest in activities, and social withdrawal.

Physical Exam:
No physical exam performed today.

Investigations:
Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without evidence of surgical pathology. Patient Health Questionnaire-9 score is 18, indicating moderate to severe depressive symptoms.

Assessment and Plan:
Discussion Summary:
Mr. Carter is diagnosed with chronic lower back pain associated with moderate to severe depression. There are no active thoughts of self-harm and no prior use of medications such as duloxetine. The relationship between chronic pain and depressive symptoms is discussed. Initiation of a low-dose serotonin-norepinephrine reuptake inhibitor, specifically duloxetine, is recommended to address both neuropathic pain and depressive symptoms. Referral to behavioral health for cognitive behavioral therapy is advised. Continuation of physical therapy and consideration of a short-term muscle relaxant are discussed.

Follow up:
Mr. Carter is advised to follow up every two to three weeks for ongoing assessment and management.