Pharmacy - Insect Bites/Stings

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

GENERAL:
PharmaNet has been checked. Eligibility confirmed.

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

PATIENT ASSESSMENT:
Mr. Carter reports persistent lower back pain that is present throughout the day, with increased severity in the mornings and after prolonged sitting. The pain interferes with sleep. He also reports significant depressive symptoms, including low mood, anhedonia, social withdrawal, and fatigue. He denies active suicidal ideation but expresses passive thoughts of not wanting to wake up. Lumbar spine magnetic resonance imaging demonstrates mild degenerative disc disease with no surgical indication.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation.

Objective:
PAST MEDICAL HISTORY:
History of chronic lower back pain and depression.

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

ALLERGIES:
No allergy information provided.

Assessment:
DIAGNOSIS:
Chronic lower back pain (M54.5), Major depressive disorder, moderate to severe (F33.1).

Plan:
RECOMMENDATIONS:
- Patient education: Mr. Carter is informed about the relationship between chronic pain and depression, and the importance of addressing both conditions concurrently.
- Mr. Carter is informed about non-pharmacological management, including continuation of physical therapy and referral for cognitive behavioral therapy with the behavioral health team.
- Treatment: Initiation of duloxetine at a low dose, with gradual titration as tolerated, is recommended. A short-term muscle relaxant may be considered for symptomatic relief of lower back pain. Instructions regarding potential side effects and the importance of adherence are provided.
- Mr. Carter has been informed that he can fill his prescription at any pharmacy of his choosing.

MONITORING/FOLLOW UP:
- Mr. Carter is advised that if he sees no improvement in 24-48 hours or his symptoms have been ongoing for more than 7 days he should see his primary care provider for further management.
- Provider notified: No information available.

Date:
2026-02-10

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