Psychiatric Intake - Pediatric PF

Subjective:
Chief Complaint:
Chronic lower back pain and depression follow-up

History of Present Illness:
- Onset: Mr. Carter reports chronic lower back pain and depressive symptoms persisting since prior visits.
- Duration: The lower back pain is present all day, every day.
- Frequency: The pain is constant, with exacerbation in the mornings and after prolonged sitting.
- Progression: There has been no improvement in pain since the last visit. Depressive symptoms have persisted, with ongoing low mood and anhedonia.
- Modifying Factors: Pain worsens in the morning and after sitting for extended periods. Sleep is disrupted due to pain.
- Associated Symptoms: Mr. Carter describes sleep disturbances, persistent low mood, loss of interest in activities, social withdrawal, and fatigue. He denies active suicidal ideation.
- Impact on Daily Life: The pain and depressive symptoms have significantly limited Mr. Carter's activities, resulting in minimal leaving of the house and reduced engagement in previously enjoyed activities.
- Previous Treatments: Mr. Carter has participated in physical therapy for his back pain. No mention of prior pharmacologic or behavioral interventions for depression.

Past Psychiatric History:
- Previous Diagnoses: Depression.
- Previous Medications: No prior use of SNRIs or similar medications.
- Previous Therapies: No previous therapies reported.
- Previous Hospitalizations: No psychiatric hospitalizations reported.
- Previous suicidal ideation or attempts: No previous suicidal ideation or attempts reported.

Substance Use History:
- Alcohol Use: No information available.
- Tobacco Use: No information available.
- Caffeine Use: No information available.
- Illicit Drug Use: No information available.

Past Medical History:
- Significant Medical Conditions: Chronic lower back pain, mild degenerative disc disease of the lumbar spine.
- Previous Hospitalizations: No information available.
- Previous Surgeries: No information available.

Current Medications:
- Current Medications: No current medications reported. No prior use of SNRIs or similar medications.
- Supplements: No information available.

Family History:
- Family History of Psychiatric Disorders: No information available.
- Other Family History: No information available.

The Review of Systems:
- General: Reports fatigue and sleep disturbances.
- Skin: No information available.
- HEENT: No information available.
- Respiratory: No information available.
- Cardiovascular: No information available.
- Gastrointestinal: No information available.
- Genitourinary: No information available.
- Musculoskeletal: Reports chronic lower back pain.
- Neurological: No information available.
- Psychiatric: Reports persistent low mood, anhedonia, social withdrawal, and fatigue.

Objective:
Mental Status Examination:
- Appearance and Behavior: No information available.
- Speech: No information available.
- Mood: Reports feeling low and tired.
- Affect: No information available.
- Thought Process: No information available.
- Thought Content: Denies active suicidal ideation.
- Perception: No information available.
- Insight: No information available.
- Judgment: No information available.
- Cognition: No information available.

Test Results:
- Laboratory Tests: No information available.
- Imaging Studies: Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease. No surgical indication on lumbar spine magnetic resonance imaging.
- Psychological Testing: Patient Health Questionnaire-9 score is 18, indicating moderate to severe depression.

Assessment:
Differential Diagnosis:
Major depressive disorder, chronic pain syndrome, mild degenerative disc disease of the lumbar spine.

Plan:
**Patient Education:**
- Educated the patient about the diagnosis of depression and chronic lower back pain, the relationship between chronic pain and mood, and the available treatment options.
- Emphasized the importance of adherence to both pharmacologic and non-pharmacologic interventions.
- Provided information on coping strategies and the benefits of behavioral health support.

**Lifestyle Modifications:**
- Advised optimizing sleep hygiene and maintaining a consistent sleep and wake schedule to improve sleep quality affected by pain.
- Recommended continuation of physical therapy and regular physical activity as tolerated.

**Treatments:**
- Initiated low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine) for management of depression and neuropathic pain.
- Considered short-term use of muscle relaxants for back pain relief.
- Referred to behavioral health team for cognitive behavioral therapy.
- No additional laboratory or imaging tests ordered at this time.

**Follow-Up:**
- Scheduled follow-up appointment in 2–3 weeks to monitor progress and adjust treatment as needed.