Pharmacy - Hemorrhoids

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Objective:
REASON FOR VISIT:
Hemorrhoids

ASSESSMENT:
Mr. Carter reports persistent, chronic lower back pain that is present throughout the day, with increased severity in the mornings and after prolonged sitting. The pain disrupts his sleep. He also describes a significant decline in mood, characterized by anhedonia, social withdrawal, and pervasive fatigue. He expresses passive thoughts of death but denies active suicidal ideation. There is no mention of bowel habit changes, rectal bleeding, or family history of colorectal cancer.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation.

Subjective:
PAST MEDICAL HISTORY:
Chronic lower back pain and depression. No prior use of SNRI or similar medications.

CURRENT MEDICATIONS:
No current medications documented. Confirmed by checking PharmaNet.

ALLERGIES:
No allergies documented.

Assessment:
DIAGNOSIS:
Hemorrhoids (K64.8)

Plan:
RECOMMENDATIONS:
- Mr. Carter is advised to maintain good fluid intake and a diet high in fibre to alleviate symptoms and reduce risk of recurrence.
- Treatment: Initiation of a low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine) for management of both mood and neuropathic pain, with gradual titration as tolerated. Referral to behavioral health for cognitive behavioral therapy. Continuation of physical therapy and consideration of a short-term muscle relaxant for back pain. Mr. Carter has been informed that he can fill his prescription at any pharmacy of his choosing.

MONITORING/FOLLOW UP:
- Follow up in 2–3 weeks to assess response to treatment.
- Mr. Carter is advised to contact his primary care provider if his symptoms do not improve or if he experiences any worsening of mood or pain.

Date:
2026-02-08

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