Routine Dental Cleaning Note

Reason for Visit:
The patient attended for evaluation and management of chronic lower back pain and depression, with persistent daily pain, difficulty sleeping, and significant mood symptoms.

Interval History:
No changes in medical history, medications, or allergies since the last visit. The patient has not previously taken duloxetine or similar medications. Lumbar spine MRI revealed mild degenerative disc disease without indications for surgical intervention.

Findings & Diagnoses:
Chronic lower back pain with MRI evidence of mild degenerative disc disease. Major depressive disorder, recurrent, moderate, as indicated by a PHQ-9 score of 18.

Treatment Recommendations & Plan:
- Initiation of low-dose duloxetine to address both mood symptoms and nerve-related pain.
- Referral to behavioral health for cognitive behavioral therapy (CBT) to assist with chronic pain and depression management.
- Continuation of physical therapy, with consideration for a short-term muscle relaxant if needed.
- Recommended follow-up appointments every 2–3 weeks to monitor progress and provide ongoing support.
- Surgical intervention is not indicated at this time.