An established 58-year-old patient is seen in the office by the nurse practitioner (NP) for a follow-up of his osteoarthritis of the knees (the physician is in the office suite). An expanded, problem-focused history is done, as well as an expanded, problem-focused examination and medical decision-making of low complexity. During the review of systems, the patient complains of pain in the right elbow, and the NP notes some swelling there. The NP decides that the patient will need a joint injection and calls in the physician. The physician reviews the patient’s chart, discusses the findings with the NP, and together they decide to administer 20 mg of Kenalog in the right elbow.
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