Surgery Consult

REFERRING PHYSICIAN: 
CONSULTANT: Jordan Lee, General Surgery

Mr. Carter was seen in consultation for chronic lower back pain and depression. The consultation was conducted in person on 2026-01-29. The patient reports persistent lower back pain that is worse in the mornings and after prolonged sitting, significantly disrupting his sleep. He also describes a consistently low mood and loss of interest in activities, with the chronic pain negatively impacting his mental health. He denies active thoughts of self-harm but admits to occasional passive thoughts due to feeling overwhelmed and fatigued. Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention. His PHQ-9 score is 18, indicating moderate to severe depression.

Mr. Carter is a male who presented with chronic lower back pain and symptoms of depression. Lumbar spine MRI demonstrated mild degenerative disc disease. The PHQ-9 score was 18, consistent with moderate to severe depression.

Clinical Findings: The patient reports daily lower back pain, worse in the mornings and after sitting, with significant sleep disruption. He describes a persistently low mood, loss of interest in activities, and passive thoughts related to feeling overwhelmed. No active suicidal ideation was reported.

PAST MEDICAL HISTORY: No significant past medical history reported.

PAST SURGICAL HISTORY: No past surgical history reported.

MEDICATIONS: Mr. Carter has never taken medications like duloxetine before.

ALLERGIES: No known allergies reported.

EXAMINATION: No physical examination findings provided.

IMPRESSION AND PLAN: Mr. Carter has chronic low back pain (M54.59) and major depressive disorder, recurrent, moderate (F33.1). The plan includes initiating a low-dose SNRI (duloxetine) to address both mood symptoms and nerve-related pain. Referral to the behavioral health team for cognitive behavioral therapy has been made. The patient will continue with physical therapy, and the addition of a short-term muscle relaxant is being considered. Follow-up appointments are scheduled every 2–3 weeks to monitor progress. Surgical intervention is not indicated for mild degenerative disc disease at this time.

Thank you for involving us in the care of this patient.