Pulmonary Clinic Template

Patient Information:
Patient Name: Jordan
Patient DOB: 
Date of Visit: February-10-2026

Subjective:
Chief Complaint:
Chronic lower back pain and depression

HPI:
Mr. Jordan presents with chronic lower back pain that has persisted without improvement since the last visit. The pain is described as constant, present throughout the day, and is exacerbated in the mornings and after prolonged periods of sitting. The pain has also been interfering with sleep. In addition to the physical symptoms, Mr. Jordan reports a persistently low mood, loss of interest in usual activities, and a tendency to remain at home unless necessary. He describes feeling as though the pain has become all-encompassing and notes significant fatigue. Mr. Jordan denies any active thoughts of self-harm but acknowledges passive thoughts of not wanting to wake up. He has not previously used medications such as serotonin-norepinephrine reuptake inhibitors. There is no mention of prior psychiatric or pain management interventions in the provided history.

ROS:
Constitutional: Reports significant fatigue. Musculoskeletal: Endorses persistent lower back pain, constant throughout the day, worsened in the morning and after prolonged sitting. Neurological: No neurological deficits reported. Psychiatric: Endorses persistently low mood, anhedonia, social withdrawal, and sleep disturbance. Denies active suicidal ideation but acknowledges passive thoughts of not wanting to wake up. No other system review findings provided.

Chronic Medical Conditions:
Chronic lower back pain. Depression.

Objective:
Diagnostic Testing:
Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease without surgical indication. Patient Health Questionnaire-9 score is 18, consistent with moderate to severe depression.

Assessment and Plan:
Impression and Plan:
1. Chronic lower back pain: Continue physical therapy. Consider initiation of a short-term muscle relaxant. 2. Depression: Initiate low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine). Refer to behavioral health for cognitive behavioral therapy. 3. Schedule follow-up in 2–3 weeks to monitor response to interventions and reassess symptoms.

Discussion:
Patient is agreeable to the plan as stated above and will follow-up in 2–3 weeks.  Patient will have  at their next appointment.

Prior pt history and records, labs and diagnostics/spirometry reviewed. Evaluated by Samuel Carter DO, FCCP, FAC, Taylor Morgan PA-C, MPAS and a med student / PA student. Pt received thorough counseling and was given the opportunity to ask questions, all of which were answered to the best of our ability and with patient satisfaction. Pt is agreeable with the treatment plan above.

Clinic Name: [Add Clinic Name Here]

Sign Off:
Thank you for your referral and collaboration today. Should you have any further questions or require additional information, please do not hesitate to reach out to our team of Dr. Samuel Carter, Alex Bennett PA-C, and Taylor Morgan PA-C