Orthodontic Malocclusion Evaluation

Patient Information:
- Name: Mr. Carter, Gender: male

Chief Complaint:
- Chronic lower back pain and depression

Medical History:
- No relevant medical history, surgeries, hospitalizations, or allergies reported. No current medications prior to this visit.

Dental History:

Social History:

Family History:

Clinical Examination:

Radiographic Examination:

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

Treatment Plan:
- Treatment Options: Initiated low-dose duloxetine (SNRI) for mood symptoms and nerve-related pain. Referral to behavioral health team for cognitive behavioral therapy (CBT). Continue physical therapy for back pain management. Discussed potential use of short-term muscle relaxant if needed. No surgical intervention indicated for mild degenerative disc disease.
- Review and Follow-up Schedule: Follow-up appointments scheduled every 2–3 weeks to monitor progress and adjust treatment as necessary.