PHC-GenSx FU CHR

I assessed Mr. David Harris today regarding chronic lower back pain and depression. 

The patient reports persistent lower back pain present daily without improvement, worse in the mornings and after prolonged sitting. He also describes difficulty sleeping due to pain, low mood, lack of interest in activities, and social withdrawal. He acknowledges that the chronic pain has significantly impacted his mental health, creating a cycle where the pain worsens his depression and vice versa. He denies active thoughts of self-harm but admits to passive thoughts, such as feeling indifferent about waking up.

Patient had the following investigations since the last assessment: 
- Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.

Physical examination findings: PHQ-9 score: 18, indicating moderate to severe depression.

Impression: Patient presents with other low back pain (M54.59) and major depressive disorder, recurrent, moderate (F33.1). The assessment is based on the patient’s report of chronic daily pain, significant mood disturbance, and MRI findings of mild degenerative disc disease without surgical indication.

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

Best regards,
Alex Chen, MD, FRCSC

“This note was generated with the assistance of automated AI Scribe software designed to support the documentation process. Information about AI Scribe is available to the patient to review. The patient provided informed verbal consent to use the AI scribe during this visit.”