Pharmacy - Vaginal Candidiasis

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Subjective:
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 describes associated sleep disturbance due to pain. He also reports a persistently low mood, anhedonia, social withdrawal, and significant fatigue. He denies active suicidal ideation but expresses passive thoughts of not wanting to wake up. There is a cyclical relationship between his chronic pain and depressive symptoms. No over-the-counter treatments or home remedies have been attempted. No previous use of serotonin-norepinephrine reuptake inhibitors or similar medications. Lumbar spine MRI demonstrates mild degenerative disc disease without surgical indication. PHQ-9 score is 18, consistent with moderate to severe depression. No history of recent antibiotic or steroid use. Smoking status not discussed.

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

Objective:
CURRENT MEDICATIONS:
No current medications reported. No prior use of serotonin-norepinephrine reuptake inhibitors or similar medications.

ALLERGIES:
No allergy information provided.

PAST MEDICAL HISTORY:
History of chronic lower back pain and depression. No information regarding potential pregnancy.

Assessment:
RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation. No surgical indication on lumbar spine MRI.

DIAGNOSIS:
Vaginal candidiasis (B37.3)

Plan:
RECOMMENDATIONS:
- Mr. Carter has been educated regarding the relationship between chronic pain and depression. Initiation of a low-dose serotonin-norepinephrine reuptake inhibitor (duloxetine) has been recommended to address both mood and neuropathic pain symptoms. Referral to behavioral health for cognitive behavioral therapy has been discussed and agreed upon. Continuation of physical therapy and consideration of a short-term muscle relaxant have been advised. Mr. Carter has been informed that he may fill his prescription at any pharmacy of his choosing.

MONITORING/FOLLOW UP:
- Mr. Carter is advised to see his primary care provider or another healthcare professional if symptoms continue beyond 7 days or return within 2 months.
- Mr. Carter is advised to contact his primary care provider if there is no improvement within 7-14 days of treatment.

Date:
2026-02-10

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