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 (initiated low-dose), physical therapy, possible short-term muscle relaxant
• Laboratory Results: Lumbar spine MRI revealed mild degenerative disc disease without indication for surgical intervention; 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 with constant pain worsening in mornings and after prolonged sitting
• 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 MRI shows mild degenerative disc disease without surgical indication
• PHQ-9 score consistent with moderate to severe depression

RECOMMENDATIONS / PLAN
• Continue physical therapy for lower back pain
• Initiate low-dose duloxetine to address depressive symptoms and neuropathic pain
• Refer to behavioral health for cognitive behavioral therapy targeting chronic pain and depression management
• Consider short-term muscle relaxant to assist with back pain management
• Schedule follow-up appointments every two to three weeks to monitor progress and adjust treatment as needed

FOLLOW-UP FOR PRIMARY CARE
• Monitor response to duloxetine and adjust dosage as needed
• Ensure adherence to physical therapy and behavioral health referrals
• Assess for any worsening depressive symptoms or suicidal ideation

Sincerely,
Alex Chen
General Practitioner
xxx@xxx.xxx