Provider-to-Provider Consultation

Date: 2026-02-08
Referring Physician: 

Dear Dr.,

PATIENT INFORMATION SUMMARY
• Diagnoses: Other low back pain (M54.59), Major depressive disorder, recurrent, moderate (F33.1)
• Medications: Duloxetine (started low-dose)
• Laboratory Results: Lumbar spine MRI revealed mild degenerative disc disease without surgical indication; PHQ-9 score was 18 indicating moderate to severe depression

REASON FOR CONSULTATION
Chronic lower back pain and depression follow-up

DISCUSSION POINTS BETWEEN PROVIDERS
• Persistent chronic lower back pain with worsening symptoms in the mornings and after prolonged sitting, disrupting sleep quality
• Significant depressive symptoms including low mood, loss of interest, social withdrawal, and passive suicidal thoughts
• Cyclical relationship between pain and depression exacerbating each other
• Lumbar spine MRI shows mild degenerative disc disease without surgical indication
• PHQ-9 score indicates moderate to severe depression

RECOMMENDATIONS / PLAN
• Initiate low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine) to address mood symptoms and neuropathic pain
• Refer to behavioral health team for cognitive behavioral therapy to manage chronic pain and depression
• Continue physical therapy for lower back pain
• Consider short-term muscle relaxant for symptomatic relief if needed
• Schedule follow-up appointments every 2 to 3 weeks to monitor progress and adjust treatment

FOLLOW-UP FOR PRIMARY CARE
• Monitor response to duloxetine and side effects
• Support adherence to cognitive behavioral therapy and physical therapy
• Assess mood and pain levels regularly

Sincerely,
Jasper Lin
xxx@xxx.xxx