Pharmacy - Headache

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Objective:
REASON FOR VISIT:
Follow-up for chronic lower back pain and depression.

PATIENT ASSESSMENT:
Mr. Carter reports persistent lower back pain present daily, with increased severity in the mornings and after prolonged sitting. The pain disrupts his sleep and is described as constant. He also reports a significantly depressed mood, loss of interest in activities, social withdrawal, and fatigue. He denies active suicidal ideation but expresses passive thoughts of not wanting to wake up. He feels that his chronic pain and depression are interrelated and mutually reinforcing. Physical assessment includes review of a lumbar spine magnetic resonance imaging, which demonstrates mild degenerative disc disease without surgical indication. A Patient Health Questionnaire-9 score of 18 is documented, indicating moderate to severe depression.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation.

Subjective:
PAST MEDICAL HISTORY:
History of chronic lower back pain and depression. No prior use of serotonin-norepinephrine reuptake inhibitors or similar medications.

CURRENT MEDICATIONS:
No current medications documented.

ALLERGIES:
No allergies documented.

Assessment:
DIAGNOSIS:
Tension-type Headache

Plan:
RECOMMENDATIONS:
- Mr. Carter is educated regarding the relationship between chronic pain and depression, and the potential benefit of serotonin-norepinephrine reuptake inhibitor therapy for both conditions.
- Mr. Carter is advised to continue physical therapy for his lower back pain.
- Initiation of a low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine) is recommended, with gradual titration as tolerated.
- Short-term muscle relaxant therapy is discussed as an adjunct for pain management.
- Referral to behavioral health for cognitive behavioral therapy is recommended to address both chronic pain and depressive symptoms.
- Mr. Carter is informed that he may fill his prescription at any pharmacy of his choosing.

MONITORING/FOLLOW UP:
- Mr. Carter is advised to schedule follow-up appointments every two to three weeks to monitor response to therapy and overall well-being.
- He is instructed to seek urgent medical attention if he experiences significant worsening of symptoms, fever, systemic symptoms, or neurological changes.

PHARMACY INFORMATION:
Pharmacy name: 
Pharmacy phone number: 
Pharmacy address: 
Pharmacist name: 
Pharmacist license number: 

Date:
2026-02-07