Urology Follow up SOAP

Subjective:
Patient History:
Mr. Carter was reassessed today in person. He reports persistent, chronic lower back pain that is present all day and worsens in the mornings and after extended periods of sitting. The pain has significantly disrupted his sleep and daily functioning. He describes a markedly depressed mood, with loss of interest in activities and social withdrawal, attributing much of his emotional distress to the ongoing pain. He acknowledges passive thoughts of wishing not to wake up but denies any active thoughts of self-harm. Recent lumbar spine magnetic resonance imaging reveals mild degenerative disc disease. There is no history of active suicidal ideation.

Urologic Summary:
1. Chronic lower back pain is present, described as constant and persistent throughout the day, with exacerbation in the mornings and after prolonged sitting.
2. The pain interferes with sleep quality.
3. No urinary incontinence or other lower urinary tract symptoms are reported.
4. Previous lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease.
5. Physical therapy is ongoing as part of the current management regimen.

Objective:
Current Medications:
No prior use of medications like duloxetine is reported. Mr. Carter is not currently taking any medications specifically for his chronic lower back pain or depression.

Assessment and Plan:
Diagnosis:
Diagnosis: Chronic lower back pain associated with mild degenerative disc disease and moderate to severe major depressive disorder, as indicated by a Patient Health Questionnaire-9 score of 18. No surgical requirement for mild degenerative disc disease.

Impression and Plan:
1. Chronic lower back pain: Continue physical therapy. Consider initiation of a short-term muscle relaxant.
2. Major depressive disorder: Initiate low-dose serotonin-norepinephrine reuptake inhibitor therapy with duloxetine to address both mood and neuropathic pain symptoms. Refer to behavioral health for cognitive behavioral therapy.
3. Schedule follow-up appointments every two to three weeks for close monitoring and support.

Clinic Name: Regional Medical Center