Musculoskeletal Oncology Initial Consult

2026-01-11
Referring Physician: 

Dear Dr. ,

REASON FOR REFERRAL
Consultation for chronic lower back pain and depression in a male patient with mild degenerative disc disease.

CONSENT
The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.

HISTORY OF PRESENTING ILLNESS
I met with Mr. Carter in the MSK Oncology Clinic today.

Mr. Carter reports persistent lower back pain that worsens in the mornings and after prolonged sitting. The pain disrupts his sleep and has not improved. He describes a significant decline in mood, feeling down most days, and losing interest in activities, rarely leaving the house unless necessary. He acknowledges that the chronic pain has impacted his mental health, creating a cycle where the pain worsens his depression, and the depression exacerbates his perception of pain. He denies active thoughts of self-harm but admits to occasional passive thoughts, such as feeling indifferent about waking up. A lumbar spine MRI shows mild degenerative disc disease not requiring surgical intervention.

PAST MEDICAL HISTORY
Otherwise healthy

PAST SURGICAL HISTORY
None

MEDICATIONS
Mr. Carter has never taken medications like duloxetine before.

ALLERGIES
No Known Allergies

PHYSICAL EXAMINATION
Patient Health Questionnaire (PHQ-9) score: 18, indicating moderate to severe depression.

DIAGNOSTICS

IMAGING
Lumbar spine MRI shows mild degenerative disc disease.

ASSESSMENT & PLAN
I have prescribed duloxetine at a low dose to help manage both mood symptoms and nerve-related pain. I have also referred Mr. Carter to the behavioral health team for cognitive behavioral therapy (CBT), which can assist in addressing chronic pain and depression. Continuation of physical therapy has been recommended to support his recovery, and I suggested considering a short-term muscle relaxant to alleviate back pain if necessary. Follow-up appointments have been scheduled every 2–3 weeks to closely monitor his progress and provide ongoing support.

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.

Please do not hesitate to contact me with any concerns.

Regards,

Dr. Morgan Lee