Vascular Surgery Consultation Letter

Dear Dr.,

Thank you for referring Mr. Carter for otolaryngology consultation. He was seen in our clinic on 2026-01-21.

CHIEF COMPLAINT/REASON FOR CONSULTATION:
Chronic lower back pain and depression follow-up

HISTORY OF PRESENT ILLNESS:
Mr. Carter presents with chronic lower back pain and depression follow-up. He reports persistent chronic lower back pain unchanged since the last visit. The pain is constant throughout the day, worsening in the mornings and after prolonged sitting. He experiences sleep disturbances due to the pain. He describes a depressed mood with anhedonia and social withdrawal, rarely leaving the house except when necessary. The pain contributes to feelings of being overwhelmed and worsens his depressive symptoms. He denies active suicidal ideation but acknowledges passive thoughts of not wanting to wake up related to fatigue and emotional exhaustion.

MEDICATIONS:
No prior use of serotonin-norepinephrine reuptake inhibitors or similar medications.

DIAGNOSTIC STUDIES:
Lumbar spine magnetic resonance imaging revealed mild degenerative disc disease without surgical indication.

ASSESSMENT & PLAN:
1. Other low back pain (M54.59)
2. Major depressive disorder, recurrent, moderate (F33.1)

I appreciate being given the opportunity to participate in the care of your patient and welcome any queries you may have regarding their care.

Sincerely,

Daniel Kim, MD, FRCSC, RPVI
Vascular and Endovascular Surgery
Regional Vascular Program
Regional Medical Center