OMFS Initial Consult Letter

Patient: Mr. Carter  
Date of Consultation: 2026-01-22  
Consultant: Jamie Lin, Dentistry

Reason for Consultation:  
Assessment and management of chronic lower back pain and depression.

History of Present Illness:  
Mr. Carter reports persistent chronic lower back pain that has not improved since his last visit. The pain is constant, present throughout the day, and worsens in the mornings and after prolonged sitting. He reports significant sleep disturbances due to the pain. He expresses feelings of depression, stating he has lost interest in activities, rarely leaves the house unless necessary, and feels the pain has taken over his life. He admits to passive thoughts about not waking up but denies active thoughts of self-harm. He describes a cycle where the pain worsens his depression, and the depression exacerbates his pain.

Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.

Oral and Maxillofacial Examination:

Assessment:

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

Plan:

1. Initiate a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), specifically duloxetine, to address both mood symptoms and nerve-related pain.
2. Referral to the behavioral health team for cognitive behavioral therapy (CBT) to assist in managing chronic pain and depression.
3. Continuation of physical therapy, with consideration for adding a short-term muscle relaxant if needed.
4. Follow-up appointments every 2–3 weeks to monitor progress and provide ongoing support.
5. 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.

Sincerely,

Jamie Lin