Otology - NEW

Mr. Carter presents with chronic lower back pain that has persisted without improvement since his last visit. The pain is constant, present throughout the day, and worsens in the mornings and after prolonged sitting. He experiences significant sleep disturbance due to the pain. He reports a persistently low mood, marked anhedonia, and social withdrawal, rarely leaving the house unless necessary. He denies active suicidal ideation but acknowledges passive thoughts of not wanting to wake up due to fatigue and emotional exhaustion. He identifies a cyclical relationship between his chronic pain and depressive symptoms, with each exacerbating the other. There is no history of prior surgical interventions or pharmacologic treatments for either condition. Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention. PHQ-9 score is 18, indicating moderate to severe depression.

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

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

Plan:
1. Initiated duloxetine at a low dose to address both mood symptoms and nerve-related pain.
2. Referral to behavioral health team for cognitive behavioral therapy to address chronic pain and depression.
3. Continue physical therapy sessions and consider short-term use of a muscle relaxant if needed.
4. Scheduled follow-up appointments every 2–3 weeks to monitor 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.