[doctor] tyler nelson , date of birth : 3 , 6 , 1949 , mrn , 385729 . he is here today for ongoing management of rheumatoid arthritis . last time he was here , he received a steroid injection in his right knee . hello mr. nelson , how are you ?
[patient] um , about the same as last time . my knee is still swollen .
[doctor] that was your right knee , correct ? i take it the injection did n't help ?
[patient] it did , maybe for a couple of weeks .
[doctor] that's it ? and is it still painful ?
[patient] yeah , it's pretty painful , and now the whole leg is getting swollen .
[doctor] okay , what would you say your pain level is ?
[patient] i mean , right now it's about a 3 or so , but , typically on a normal day it's around 6 .
[doctor] okay , and its been swollen like that for how long now ?
[patient] since i was last here a couple weeks after that . so about , maybe two months now .
[doctor] okay , but before it was just the knee ?
[patient] yeah , the whole thing was n't swollen like this , but i tried to wear compression socks a lot of the time , but it has n't been helping .
[doctor] okay , okay , so that has n't been working for you ?
[patient] i mean , it helps to some degree , but it's still swollen , especially around the knee .
[doctor] hmm . has it been keeping you from doing things during the day ?
[patient] well , i slowed down a little bit , and i found a few things too fast . but when it really hurts , is when i've been sitting for a while , and then i have to try and get up . i'm so stiff getting up i have to use a cane to get my bearings . i mean , after a little bit , it loosens up , but that first getting up is real difficult .
[doctor] yeah , i can see , that makes sense . have you been taking your medication regularly ? your on xeljanz right ?
[patient] yeah , the xr , i think its , uhm , 11 milligrams a day ? yeah , but i'm taking it everyday , and i'm also taking celebrex which i started maybe 2 months ago .
[doctor] yes , the 200mgs daily . how's that working for you ?
[patient] pretty good , up until it started swelling again .
[doctor] okay , well come sit over here , and if you could take of your socks and shoes , and we'll take a look at your knee . and just to let you know , i have a service now that writes my note about the visit , so you'll hear me call things out and describe what i see fully .
[patient] okay , gotcha .
[doctor] right , so let's check your leg . can you straighten it , and does it hurt ?
[patient] yeah , when i try to straighten it all the way it does .
[doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ?
[patient] um , just kinda sore , like an old bruise ?
[doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from .
[patient] yeah . let's do it . sounds go to me .
[doctor] okay , and did we set up physical therapy for you last time you were here ?
[patient] yeah , that was some years ago , but that was the other knee .
[doctor] okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee .
[patient] okay , sounds like a plan .
[doctor] all right , so for today we'll go ahead and we'll give you the steroid shot . i'll try to see if i can get a little bit of fluid out before i do give you the injection . there might be no fluid , but i'll see if i can get anything out regardless .
[patient] okay . and that's a procedure you're going to do right now ?
[doctor] yep . once we're done talking here , and as far as the edema in your legs , uh , we'll take an x-ray to look for the cause , but there is a lot you can do as well . the compression socks are a good start . um , and also , do you eat a lot of salt ?
[patient] i mean , um , i mean i love my salty snacks .
[doctor] okay . well , salt does have a tendency to make your body hold on to water , reducing your salt intake could help with some of the swelling . you can also prop your feet up any time you get a chance , especially at night . and have you talked to your private care doctor about this at all ?
[patient] no , i figured i would just come here first .
[doctor] okay . so i think , try some of those things out first , and if it does n't help , definitely make an appointment with them , also , as you know , xeljanz is a high-risk medication , so we need to check your cmp levels every couple of months . so this time your levels are good , but do make sure to make an appointment for the blood work for next time .
[patient] all right . i can do that . thank you so much doc .
[doctor] yes , of course . well let me go ahead and get supplies and we'll get to work on your knee .
[doctor] fluid aspiration and steroid injection procedure . the risks , benefits , and alternatives were explained . the risks of steroid injection were explained , including , but not limited to : hypopigmentation , soft tissue atrophy , tendon ruptures , and transient hypoglycemia among others . verbal consent was attained . the right knee was , uh , um , accessed through the lateral approach with 3 milliliters of initially clear fluid , then bloo- blood tinged fluid . then the right knee was prepped in a standard-fashion . the right knee was injected with 80 milligrams of triamcinolone , and one milliliter of lidocaine . the procedure was tolerated well , with no complications . post-procedure instructions were given . patient will follow up with his pcp . thank you .

Medical orders:
description: cmp couple of months blood
order_type: lab
reason: high-risk medication
description: x-ray of that knee knee
order_type: imaging
reason: rheumatoid arthritis swelling