Mary, age 51, returns to the rheumatology office for a follow-up visit for rheumatoid arthritis in her left hand, left elbow and neck (without rheumatoid factor). The physician takes a detailed history, performs an expanded problem focused exam and the medical decision is low complexity.
During the visit, the patient complains of stiffness and swelling in the left hand, left elbow and neck. The rheumatologist performed an X-ray of the left hand, two views and read the results during the visit. Because of the severity of the swelling, the rheumatologist decided to give the patient a joint injection in the first finger on the left hand.