Pediatric Rheumatology Initial Consult

PEDIATRIC RHEUMATOLOGY CONSULT

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.

Thank you for referring this male who I saw in the clinic on 2026-01-24. Jordan was accompanied by their 

Our provisional diagnosis is: Chronic lower back pain and moderate to severe depression

HISTORY OF PRESENTING ILLNESS:
Jordan was referred to the Rheumatology clinic for: Chronic lower back pain and depression

Symptoms: He reports that his lower back pain has not improved since the last visit and describes the pain as constant, present throughout the day, and most severe in the mornings and after prolonged periods of sitting. He states that his sleep quality has been poor due to the pain. He endorses persistent low mood, anhedonia, and significant social withdrawal, noting that he rarely leaves his home except when necessary. He denies active suicidal ideation but admits to passive thoughts of death, expressing fatigue and a sense of hopelessness. He recognizes a cyclical relationship between his chronic pain and depressive symptoms, with each exacerbating the other.

Functional status: Significant social withdrawal and rarely leaves his home except when necessary.

Review of systems:
Psychological: Mr. Jordan endorses persistent low mood, anhedonia, and significant social withdrawal. He denies active thoughts of self-harm but admits to passive thoughts of death, expressing fatigue and a sense of hopelessness.

Therapies tried:
He continues with physical therapy as part of his management. He has not previously been treated with serotonin-norepinephrine reuptake inhibitors or engaged in cognitive behavioral therapy.

PAST MEDICAL HISTORY:
Medical diagnoses: Chronic lower back pain and associated depressive symptoms. Previous lumbar spine magnetic resonance imaging demonstrated mild degenerative disc disease without surgical indications.
Surgeries: 
Medications:
Mr. Jordan has not previously used medications like duloxetine.
Allergies:

FAMILY HISTORY:

SOCIAL HISTORY:
Mr. Jordan reports significant social withdrawal and rarely leaves his home except when necessary.

PHYSICAL EXAMINATION:

INVESTIGATIONS:
Lumbar spine magnetic resonance imaging demonstrated mild degenerative disc disease without surgical indications.
Patient Health Questionnaire (PHQ-9) score: 18, indicating moderate to severe depression.

IMPRESSION:
Mr. Jordan presents with chronic lower back pain and moderate to severe depression, with symptoms of persistent low mood, anhedonia, and social withdrawal. His condition is compounded by a cyclical relationship between pain and depression.

RECOMMENDED MANAGEMENT:
1. Prescribed 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 his chronic pain and depression.
3. Continue with physical therapy as part of his back pain management plan. If necessary, potential addition of a short-term muscle relaxant to further alleviate back pain.

FOLLOW UP:
Follow-up appointments have been scheduled every 2–3 weeks to closely monitor his progress and make any necessary adjustments to the treatment plan.

Sincerely,

Alex Chen