Pharmacy -- Urinary Tract Infection

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 that is present throughout the day, with increased severity in the mornings and after prolonged sitting. He experiences significant sleep disturbance due to the pain. He describes a markedly depressed mood, loss of interest in activities, and social withdrawal. He denies active suicidal ideation but expresses passive thoughts of not wanting to wake up. Physical assessment findings are not documented in this encounter.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation is reported. No additional red flag symptoms or indications for urgent referral are documented.

Subjective:
PAST MEDICAL HISTORY:
History of chronic lower back pain and depression. No other significant past medical history provided.

CURRENT MEDICATIONS:
No prior use of serotonin-norepinephrine reuptake inhibitor or similar medications. No other current medications are documented. Medication history confirmed by checking PharmaNet.

ALLERGIES:
No allergies to drugs, foods, or environmental agents are reported.

Assessment:
DIAGNOSIS:
Chronic lower back pain (M54.5) and moderate to severe major depressive disorder (F33.1) (PHQ-9 score 18). No surgical indication on lumbar spine magnetic resonance imaging.

Plan:
RECOMMENDATIONS:
- Patient education provided regarding the relationship between chronic pain and depression.
- Initiation of low-dose duloxetine is recommended to address both mood and neuropathic pain symptoms.
- Referral to behavioral health for cognitive behavioral therapy is advised.
- Continuation of physical therapy for lumbar spine pain is recommended.
- Consideration of a short-term muscle relaxant for symptomatic relief.
- Mr. Carter is encouraged to maintain regular follow-up and is reassured of ongoing support.

MONITORING/FOLLOW UP:
- Mr. Carter is advised to attend follow-up appointments every 2–3 weeks to monitor response to treatment and address any emerging concerns.
- He is instructed to seek urgent medical attention if he develops new or worsening symptoms, including fever, chills, or acute neurological changes.

DATE:
2026-02-01

PHARMACY INFORMATION:
Pharmacy name: 
Pharmacy phone number: 
Pharmacy address: 
Pharmacist name: 
Pharmacist license number: 
Date: 2026-02-01