PHC-Breast Surgery Consult

REFERRING PHYSICIAN: Dr. Olivia Carter, Family Medicine 
CONSULTANT: Dr. Daniel Lee, General Surgery

I assessed Mr. Parker at the Regional Breast Centre today. He was referred because of chronic lower back pain and depression.
He is an English-speaking gentleman.

History of present illness
Mr. Parker reports persistent lower back pain that has been present daily without improvement. He describes the pain as being worse in the mornings and after prolonged sitting. He also reports difficulty sleeping due to the pain. The chronic pain has significantly impacted his mental health, creating a cycle where the pain exacerbates his depression and vice versa. He denies active thoughts of self-harm but admits to occasional passive thoughts, such as wishing he would not wake up, due to feeling overwhelmed and fatigued. Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention. Patient Health Questionnaire (PHQ-9) score: 18, indicating moderate to severe depression.

PAST MEDICAL HISTORY: Not available.

PAST SURGICAL HISTORY: Not available.

MEDICATIONS: Mr. Parker has never taken medications like duloxetine before.

ALLERGIES: Not available.

SOCIAL HISTORY: Not available.

IMPRESSION AND PLAN:
Mr. Parker has mild degenerative disc disease of the lumbar spine and major depressive disorder, recurrent, moderate. The treatment plan includes starting Mr. Parker on a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), specifically duloxetine, to target 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 his 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,
Daniel Lee, MD, FRCSC