Pharmacy - Mouth Ulcer

PATIENT DETAILS:
Name: Ms. Parker
Phone number: 
Personal Health Number (PHN): 

GENERAL:
PharmaNet has been checked. 

Objective:
REASON FOR VISIT:
Mouth ulcer

ASSESSMENT:
Ms. Parker reports persistent fatigue for approximately three months, associated with weight gain, irregular menstruation, morning joint stiffness, hair thinning, constipation, and cold intolerance. Family history is notable for maternal Hashimoto’s thyroiditis. 

Physical assessment and oral examination findings are not documented in the transcript.

Subjective:
PAST MEDICAL HISTORY:
No significant findings.

CURRENT MEDICATIONS:
No information available.

ALLERGIES:
No information available.

Assessment:
DIAGNOSIS:
Oral ulcer

Plan:
RECOMMENDATIONS:
- Ms. Parker is advised regarding non-pharmacological management of symptoms, such as avoiding irritating food (e.g. spicy or acidic foods), avoiding toothpaste containing sodium laurel sulphate, and brushing teeth twice daily.
- Treatment: Document details of prescribed topical treatment including dosage, frequency, duration of treatment, and instructions.
- Ms. Parker is advised to avoid eating/drinking for minimum 30 minutes after application of topical medication.

MONITORING/FOLLOW UP:
- Follow up in 7 days to assess response and adherence to treatment.
- Ms. Parker is advised to contact their primary care provider if their symptoms worsen or do not improve after 7 days. Treatment should not be continued for longer than 14 days.

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

DATE:
2026-02-06