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), physical therapy continued, short-term muscle relaxant considered
• Laboratory Results: Lumbar spine MRI showed mild degenerative disc disease without surgical indication; PHQ-9 score 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 worsening in mornings and after prolonged sitting, disrupting sleep
• Moderate to severe depression with loss of interest, social withdrawal, and passive suicidal thoughts
• MRI findings show mild degenerative disc disease without surgical indication
• PHQ-9 score supports diagnosis of moderate to severe depression
• Pain and depression cycle contributing to symptom severity

RECOMMENDATIONS / PLAN
• Initiate low-dose 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 back pain
• Consider short-term muscle relaxant for adjunctive symptom relief
• 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 during follow-up visits

Sincerely,
Evan Lin
General Practitioner
xxx@xxx.xxx