Pharmacy - Musculoskeletal Pain/Strain

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Objective:
REASON FOR VISIT:
Persistent fatigue.

ASSESSMENT:
Ms. Parker reports persistent fatigue for approximately three months. Additional symptoms include weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and cold intolerance. There is a family history of autoimmune thyroid disease (mother with Hashimoto’s thyroiditis). Laboratory investigations reveal elevated thyroid stimulating hormone at 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies, consistent with autoimmune hypothyroidism. Mild vitamin D deficiency is also noted. On physical assessment, there is no documentation of swelling, bruising, erythema, warmth, tenderness, or visible deformity.

Subjective:
PAST MEDICAL HISTORY:
No significant findings.

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

ALLERGIES:
No allergies reported.

Assessment:
DIAGNOSIS:
Muscle strain/sprain (S46.31)

Plan:
RECOMMENDATIONS:
- Ms. Parker has been educated regarding the importance of medication adherence and avoidance of calcium or iron supplements within 30 minutes of levothyroxine administration. She has been advised to maintain a balanced diet, engage in regular light physical activity, and increase sunlight exposure for vitamin D. Levothyroxine 50 micrograms daily and vitamin D 2000 IU daily have been prescribed. Ms. Parker has been advised of the importance of not exceeding the recommended dosage of prescribed medications due to risks of toxicity, including potential renal or liver damage and peptic ulcers.
- She should start mobilizing after 48 hours and consider seeking physiotherapy if needed.

MONITORING/FOLLOW UP:
- Follow up in 1-2 weeks to assess efficacy of treatment, any adverse reactions, and resolution of symptoms.
- Ms. Parker is advised to contact her primary care provider if symptoms are worsening or have not resolved within 2 weeks.

Date:
2026-02-07

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