Post Dental visit Patient Handout

Dear Mr. Carter,

We are providing you with a summary of your recent medical visit to help you better understand your health and the care you received. This summary includes details about your examination, any findings, treatments discussed, and recommendations for future care.

Your Medical Examination:

During your appointment, we discussed your ongoing back pain and feelings of low mood. We reviewed your lumbar spine MRI and your responses to a mood questionnaire.

What We Found:
- Your MRI showed mild wear and tear in the discs of your lower back, but nothing that requires surgery.
- Your mood questionnaire score suggests moderate to severe depression.

Treatments Discussed:
- Starting a low-dose medication called duloxetine, which can help with both mood and nerve-related pain.
- Continuing physical therapy for your back pain.
- Adding a short-term muscle relaxant if needed.
- Referring you to behavioral health for therapy to help manage both your pain and mood.

Our Recommendations for You:
- Take the prescribed medication as directed.
- Attend physical therapy sessions regularly.
- Follow up with the behavioral health team for therapy.
- Schedule a follow-up appointment in 2–3 weeks to check on your progress.

Next Steps & Follow-Up Appointments:
- Your next recommended visit: In 2–3 weeks.
- Treatment still needed: Continue with the above plan.
- Referrals: Behavioral health for therapy.

Your Questions Answered:
- You mentioned feeling stuck in a cycle of pain and low mood. We discussed how the treatments above aim to address both issues together.

Contact Us:
If you have any questions or concerns about your treatment, please don’t hesitate to contact us. We are here to help you understand and feel comfortable with your care.

We appreciate the opportunity to care for you and look forward to seeing you at your next visit.

Sincerely,
Dr. Daniel Lee