PHC-Breast Cancer Treatment Summary and Follow-Up

I saw Mr. Carter at the clinic today for follow-up regarding his chronic lower back pain and associated depression.

Mr. Carter presents with chronic lower back pain that has persisted daily without improvement. The pain is worse in the mornings and after prolonged sitting, and it has significantly disrupted his sleep. He reports feeling overwhelmed by the pain and its impact on his life. While he denies active thoughts of self-harm, he admits to occasional passive thoughts, such as wishing he would not wake up. He reports feeling trapped in a cycle where the pain exacerbates his depression, and the depression worsens his perception of pain. He reports significant social withdrawal and rarely leaves the house unless necessary.

His PHQ-9 score is 18, indicating moderate to severe depression. Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.

The plan includes initiating a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), specifically duloxetine, to address both mood symptoms and nerve-related pain. A referral has been made to the behavioral health team for cognitive behavioral therapy (CBT) to aid in managing chronic pain and depression. Continuation of physical therapy is recommended, with consideration for adding a short-term muscle relaxant if needed. Follow-up appointments are planned every 2–3 weeks to monitor the patient’s 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.

Thank you for involving us in the care of this patient.

Best regards,

Jordan Lee

* This note was generated with the assistance of automated AI Scribe software designed to support the documentation process. The patient had provided informed verbal consent to use the AI scribe during this visit.