Inpatient Urology Consult

Urology Inpatient Consultation  
2026-02-09

Patient: Mr. Carter  
Reason For Consultation: Chronic lower back pain and depression

History of Present Illness: Mr. Carter is a male seen for evaluation of chronic lower back pain and depression. The patient reports persistent lower back pain that is constant, worse in the mornings and after prolonged sitting, and has not improved since the last visit. He also notes difficulty sleeping due to the pain, and states that the pain has negatively impacted his daily life and mental health. No recent surgeries or interventions.

Current Medications:
- Duloxetine

Labs, Imaging & Other Studies: 
- 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.

ASSESSMENT AND PLAN: 
Male with other low back pain and major depressive disorder, recurrent, moderate.
1. Other low back pain (M54.59)
Assessment: Persistent lower back pain with MRI evidence of mild degenerative disc disease, not requiring surgical intervention.
Plan: 
- Continue physical therapy.
- Consider short-term muscle relaxant if necessary.
- Monitor progress with follow-up appointments every 2–3 weeks.

2. Major depressive disorder, recurrent, moderate (F33.1)
Assessment: Moderate to severe depression as indicated by PHQ-9 score of 18, with symptoms of low mood, loss of interest, and fatigue.
Plan: 
- Initiate low-dose duloxetine.
- Refer to behavioral health team for cognitive behavioral therapy (CBT).
- Monitor progress with follow-up appointments every 2–3 weeks.