Pediatric Rheumatology OP follow up

PEDIATRIC RHEUMATOLOGY OUTPATIENT NOTE

I saw Mr. Carter for a follow up on 2026-02-02. Mr. Carter is a male.

The patient/ caregiver 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.

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

DISEASE ASSESSMENT SCORES:
Physician global assessment of disease activity: Moderate to severe depression (PHQ-9 score: 18)

CURRENT MEDICATIONS:
Mr. Carter has not previously been treated with serotonin-norepinephrine reuptake inhibitors such as duloxetine.

MEDICATION CHANGES MADE TODAY:
Duloxetine was prescribed at a low dose to address both mood symptoms and nerve-related pain. A short-term muscle relaxant was suggested if needed for additional relief.

INTERVAL HISTORY:
Symptoms: Mr. Carter reports chronic lower back pain that has not improved since the last visit. The pain is constant, most severe in the mornings and after prolonged sitting, and disrupts his sleep. He endorses persistent low mood, anhedonia, and social withdrawal, rarely leaving his home except when necessary. He denies active suicidal ideation but admits to passive thoughts of not wanting to wake up, attributing this to ongoing fatigue and emotional exhaustion. He recognizes a cyclical relationship between his chronic pain and depressive symptoms, with each exacerbating the other. There have been no recent hospitalizations or new neurological deficits.

Medication adherence & tolerance: He continues to participate in physical therapy. No prior use of duloxetine or other SNRIs.

Functional status: The patient has severe limitations in daily activities, including significant social withdrawal and rarely leaving his home except when necessary.

Review of Systems: General: Reports fatigue and disrupted sleep due to chronic pain. Psychological: Endorses persistent low mood, anhedonia, and social withdrawal. Denies active thoughts of self-harm but admits to passive thoughts of not wanting to wake up. Musculoskeletal: Reports constant lower back pain, worse in the mornings and after prolonged sitting.

PHYSICAL EXAMINATION:
Patient Health Questionnaire (PHQ-9) score: 18, indicating moderate to severe depression.

INVESTIGATIONS:
Lumbar spine magnetic resonance imaging demonstrated mild degenerative disc disease without surgical indications.

IMPRESSION:
Mr. Carter presents with chronic lower back pain and moderate to severe depression, with symptoms significantly impacting his daily functioning and quality of life. Imaging findings reveal mild degenerative disc disease without surgical indications.

PLAN:
1. Initiate duloxetine at a low dose for management of mood symptoms and nerve-related pain.
2. Refer to behavioral health team for cognitive behavioral therapy (CBT) to support management of chronic pain and depression.
3. Continue physical therapy for back pain.
4. Consider short-term muscle relaxant if needed for additional relief.
5. Schedule follow-up appointments every 2–3 weeks to monitor progress and adjust treatment as necessary.

Thank you for involving me in the care of Mr. Carter. Please do not hesitate to contact us for any questions or concerns.