Nephrology New Consultation

Thank you for your referral of this pleasant male for investigation and management of his chronic lower back pain and depression. He was seen in the office with his consent on 2026-02-01.

In person appointments are now being offered to all patients, but due to the COVID-19 pandemic, I am still providing the option of a virtual consult via videoconference if preferred. Telephone consults are only being provided where there is no other feasible option at present.

Medical History:
- Chronic lower back pain
- Depressive symptoms
- Mild degenerative disc disease on lumbar spine MRI (no surgical indications)

Past Surgical History:

History of presenting illness:
Mr. Carter reports persistent lower back pain without improvement since the last visit. The pain is constant, present throughout the day, and worsens in the mornings and after prolonged sitting. It significantly disrupts his sleep, leading to poor sleep quality. He describes a persistently low mood with marked anhedonia, stating he has lost interest in most activities and rarely leaves his home except when necessary. He denies active suicidal ideation but admits to passive thoughts of death, expressing indifference about waking up. He identifies a cyclical relationship between his chronic pain and depressive symptoms, with each exacerbating the other. Previous lumbar spine MRI showed mild degenerative disc disease without surgical indications. No recent hospitalizations or changes in chronic disease management were noted. He has not trialed serotonin-norepinephrine reuptake inhibitors or cognitive behavioral therapy. No additional symptoms or concerns were reported.

Review of systems:
• Musculoskeletal: Chronic lower back pain that is constant and worsens in the mornings and after prolonged sitting.
• Psychological: Persistently low mood, marked anhedonia, and passive thoughts of death. No active thoughts of self-harm.

Current Medications:
No prior use of medications like duloxetine.

Known Allergies:
None Known.

Social History:
Mr. Carter rarely leaves his home except when necessary, indicating a significant impact on his daily activities due to his symptoms.

Physical examination:

Laboratory examination:

Imaging: 
- Lumbar spine MRI: Mild degenerative disc disease without surgical indications

Impression and Plan:
Mr. Carter presents with chronic lower back pain and moderate to severe depressive symptoms, as evidenced by a PHQ-9 score of 18 and MRI findings of mild degenerative disc disease. I have prescribed a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), duloxetine, to address both mood disturbances and nerve-related pain. Additionally, I have referred Mr. Carter to the behavioral health team for cognitive behavioral therapy (CBT) to help manage his chronic pain and depressive symptoms. Continuation of physical therapy has been recommended to support the management of his chronic lower back pain. I have also proposed the addition of a short-term muscle relaxant to provide symptomatic relief. Follow-up appointments have been scheduled every 2–3 weeks to monitor his progress and make any necessary adjustments to the treatment plan.

I will see Patient in follow-up in 2–3 weeks. If you have any concerns prior to the next appointment, please don't hesitate to contact my office. Thank you for involving me in this pleasant patient’s care.