A 60-year-old female with severe RA presents for her third dosage of infliximab (the patient is currently on methotrexate and prednisone). A chest X-ray and tuberculosis skin test were ordered and reviewed prior to the day of the infusion. The patient’s rheumatologist is on vacation, so she has to see his partner (who has never treated the patient). The rheumatologist does a brief encounter to ensure that it is safe for the patient to have the infusion. The physician questions and examines the patient to make sure there is no active infection; he reviews the skin text and X-ray report. He recommends the patient go ahead and begin the infliximab infusion. The patient had no additional questions. An extended counseling session to review the risks and benefits of infliximab did not need to be repeated because the patient’s usual rheumatologist had done this during the last visit. A problem-focused history and examination are done. The medical decision-making is of low complexity. The patient is infused for two hours and 38 minutes with 600 mg of infliximab.
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