Nurse Practitioner Problem-Oriented Visit Note

HPI

1. Right knee pain

58 yo M presents with 3-wk hx of R knee pain. Insidious onset, worse with stairs and prolonged standing. Describes dull ache, 5/10 severity. Morning stiffness < 20 mins. Denies trauma, locking, giving way, fever, or erythema. Minimal relief with OTC paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN.

2. Essential hypertension

Here for routine f/u and med refill. Adherent to lisinopril 20 mg PO daily. Home BP log shows avg 146/88 mmHg over past 2 wks. Denies HA, vision changes, CP, or SOB.

3. Type 2 diabetes mellitus

Routine f/u. Adherent to metformin 1,000 mg PO BID. Fasting fingersticks 110–135 mg/dL. Denies polyuria, polydipsia, hypoglycaemic episodes, or paresthesias. Due for routine labs and eye exam.

Review of systems

Constitutional: Negative for fever, chills, wt loss. CV: Negative for CP, palpitations, orthopnea, LE edema. Resp: Negative for SOB, cough. MSK: Positive for R knee pain and brief morning stiffness. Negative for other joint pain or swelling. Neuro: Negative for numbness, tingling, weakness, dizziness.

Physical exam

Vitals: T 36.8 °C, HR 76 bpm, BP 148/90 mmHg, RR 14/min, SpO2 98 %, Wt 92.5 kg, BMI 29.8 kg/m². Gen: A&O x3, NAD. CV: RRR, normal S1/S2, no murmurs/rubs/gallops. Distal pulses 2+ bilaterally. No peripheral edema. Resp: CTAB, no wheezes/rales/rhonchi. MSK (R knee): Mild crepitus on passive ROM. Trace effusion, no warmth or erythema. Tenderness along medial joint line. Full extension, flexion limited to 115 degrees d/t pain. McMurray, Lachman, and anterior/posterior drawer tests negative. Valgus/varus stress stable. Neuro/Foot exam: Monofilament 10/10 intact bilaterally. Skin intact, no ulcers or calluses.

Assessment & Plan

1. Right knee pain

• Osteoarthritis of right knee
• Differential: Degenerative medial meniscal tear, pes anserine bursitis.
• Investigations: X-ray R knee (standing AP, lateral, sunrise views).
• Treatment: Start diclofenac 1 % topical gel (Voltaren®) 4 g topically to R knee QID. Wt loss and low-impact exercise counselled.
• Referrals: Physical therapy for quadriceps strengthening.

2. Essential hypertension

• Uncontrolled essential hypertension
• Investigations: BMP to check baseline renal function and K+ prior to med adjustment.
• Treatment: Increase lisinopril to 40 mg PO daily. Continue low-Na diet. Recheck BP in 4 wks.

3. Type 2 diabetes mellitus

• Type 2 diabetes mellitus without complications
• Investigations: HbA1c, lipid panel, urine albumin-to-creatinine ratio.
• Treatment: Continue metformin 1,000 mg PO BID. F/u in 3 mos.
• Referrals: Ophthalmology for annual dilated diabetic eye exam.