Problem-Based Primary Care Note
Created by
Jennifer Miller
Specialty
Family Medicine Specialist
Last edited
10/20/2026
Uses
0 times
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About this template
A structured template for documenting primary care visits by individual problem, issue, or request. It covers the history of present illness, relevant review of systems, physical examination, and an assessment and plan for each concern.
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HPI
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Right knee pain
- Onset 3 weeks ago after increasing daily walking distance.
- Aching pain localized to medial joint line, rated 4/10.
- Worse with stairs and prolonged standing; improved with rest.
- Denies locking, catching, giving way, or acute trauma.
- Partial relief with paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN.
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Hypertension follow-up
- Home BP readings averaging 132/82 mmHg over the past month.
- Adherent to lisinopril 20 mg PO daily with no side effects.
- Requests prescription refill.
Review of Systems
Constitutional Denies fever, chills, or unintentional weight loss.
Cardiovascular Denies chest pain, palpitations, or lower extremity edema.
Respiratory Denies SOB or cough.
Musculoskeletal Negative for other joint pain, morning stiffness > 30 mins, or erythema.
Physical Exam
Vitals BP 128/78 mmHg, HR 72 bpm, Temp 36.8 °C, Weight 84 kg, BMI 27.4 kg/m².
General Alert, oriented, in NAD.
Cardiovascular RRR, normal S1/S2, no murmurs, rubs, or gallops.
Respiratory CTAB, no wheezes or crackles.
Right Knee No erythema, warmth, or effusion. Tenderness to palpation along medial joint line. Full ROM with mild crepitus. McMurray, Lachman, and valgus/varus stress tests negative. Normal gait.
Assessment & Plan
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Right knee pain
- Assessment: Osteoarthritis of right knee
- Differential diagnosis: Medial meniscal tear, pes anserine bursitis.
- Investigations: X-ray right knee (weight-bearing AP, lateral, sunrise views).
- Treatment plan: Start ibuprofen (Advil®) 400 mg PO TID PRN with food for 10 days. Discussed weight management and low-impact exercises (swimming, cycling).
- Referrals: Physical therapy for quadriceps strengthening.
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Hypertension follow-up
- Assessment: Essential hypertension
- Investigations: BMP and lipid panel ordered for routine annual monitoring.
- Treatment plan: Continue lisinopril 20 mg PO daily (refill x 90 days with 3 repeats). Continue home BP monitoring and low-sodium diet. RTC in 6 months.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.