Pharmacy - Acne Vulgaris

PATIENT DETAILS:
Name: Mr. Carter
Phone number: 
Personal Health Number (PHN): 

GENERAL:
PharmaNet has been checked. No information available regarding eligibility.

Objective:
PATIENT ASSESSMENT:
Mr. Carter reports persistent lower back pain present daily, with increased severity in the mornings and after prolonged sitting. He experiences significant sleep disturbance due to pain. He describes a markedly depressed mood, anhedonia, social withdrawal, and passive thoughts of death but denies active suicidal ideation. On assessment, lumbar spine MRI demonstrates mild degenerative disc disease without surgical indication. PHQ-9 score is 18, indicating moderate to severe depression.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation.

Subjective:
PAST MEDICAL HISTORY:
Mr. Carter has a history of chronic lower back pain and depression. No information provided regarding pregnancy or lactation status.

CURRENT MEDICATIONS:
No prior use of SNRIs or similar medications.

ALLERGIES:
No allergies documented.

Assessment:
DIAGNOSIS:
Chronic lower back pain (M54.5) and major depressive disorder (F33).

Plan:
RECOMMENDATIONS:
- Self care advice: Mr. Carter advised to gently cleanse skin with warm water and mild soap 1-2 times/day, and only use non-comedogenic skin products. He is advised to avoid scrubbing, touching or picking at pimples as this may cause scarring.
- Topical Treatment: Document details of any over the counter (OTC) or prescription medication that is recommended, including strength, frequency, and instructions.
- Mr. Carter advised to ensure topical treatment is applied to the entire affected area, not just isolated lesions. The condition may worsen in the first 2-4 weeks of treatment before showing improvement.
- To minimize initial skin irritation from topical treatment he can apply it every other day or three times weekly and gradually increase to daily.
- Mr. Carter is advised regarding the importance of adherence to treatment regime and that it may take up to 2 months to see a visible improvement to his acne.
- Patient advised to see another healthcare provider (e.g. family doctor) for further assessment and treatment for moderate/severe acne.
- Mr. Carter has been informed that they can fill their prescription at any pharmacy of their choosing.

MONITORING/FOLLOW UP:
- Follow up in 2-3 months to assess response to treatment.
- Mr. Carter is advised that if he experiences any allergic reaction he should discontinue treatment and seek further medical assistance if necessary.
- Responding well to treatment: Mr. Carter is advised to continue maintenance therapy as prescribed.
- No/insufficient improvement: Mr. Carter is advised that after two failed trials of treatment, he  will be referred to see his family doctor for further treatment or a specialist referral.
- Worsening of acne: Mr. Carter advised that if acne has worsened at his follow up appointment, he will be referred to a family doctor for further management.
- Provider notified: document if patient’s provider has been notified and if yes note their name and practice information.

DATE:
2026-02-02

PHARMACY INFORMATION:
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Pharmacy phone number: 
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