82-year-old female with a history of rheumatoid arthritis.  Some components of scleroderma and documented Raynaud's disease without previous major ulceration or ischemia.  She received her third covid-19.  Vaccination outside the office, which was a Moderna booster shot 12/13/21.  About 2 weeks later she began to have pain and dystrophic changes in her left ring finger..  This progressed and she actually developed dry gangrenous area.  She was seen by the nurse practitioner 1/21 and referred to Dr.  She was started on antibiotics, but it looks like she has some dry gangrenous ischemic change without evidence of infection at the distal portion of the finger.  She has been treated conservatively.  It's improving, seems to be drying up.  There is no evidence of infection.  Her pain is improved.  She questioned whether it may have happened related to the vaccination.  The timeframe is interesting.  She does have a history of some minimal transient ulcers, but nothing like this previously.  We are going to give her some lidocaine used for symptomatic relief.  The surgeon is following her.  At this point were just dry up demarcate and resolved without additional treatment.  Looks like she will have some loss of the fingertip.  The other fingers look well perfused.  We did review treatment of the Raynaud's disease.  She has had a calcium blocker for years.  She also has some Nitro-Bid ointment.  She understands if she has something like this happen again to seek treatment, sooner HPI:   No additional activity is noted upon review of the problem list.  ROS:    Denies other cardiac, pulmonary, GI, GU, endocrine, infectious, neurologic, musculoskeletal or other complaint.  Nursing staff indicates no other complaint.     Current Meds: Acetaminophen-Codeine #3 300-30 mg, Amlodipine Besylate 10 mg, Nitro-bid 2 %, Atorvastatin Calcium 40 mg, Clopidogrel Bisulfate 75 mg, Atenolol 25 mg, Methotrexate 2.5 mg, Folic Acid 1 mg, Aspirin 81 mg, Vitamin D-3 1000 Unit, MSM 1000 mg, Coq10 100 mg Allergies:    Sulfa - Nausea, Nitroglycerin, Ace 1 Inhibitors  PMH: Immun/Inj. Record: 90658-Influenza Virus Split 3 Yrs And Above For Intramuscular Use 00/00/00 Q2037-Flu Shot 11/07/16 10/21/15 11/03/14 01/10/14 10/05/12 11/14/11 91306-Moderna Covid-19 Vaccine (Low Dose) Booster .25mL 12/13/21 91300.2-Covid 19 Vaccine (Pfizer 2ND Dose) 03/26/21 91300.1-Covid 19 Vaccine (Pfizer 1St Dose) 03/05/21 90756-Flucelvax, Multi-Dose Vial, 5 ML 12/06/21 09/09/20 90732-Pneumococcal Vaccine 01/09/13 90715-Tetanus, Diphtheria Toxoids/Acellular Pertussis Vaccine 7 Or > 01/09/13 90688-Afluria, Multi-Dose Vial, 5ML 11/08/19 10/11/18 11/21/17 90670-Pneumococcal Conjugate Vaccine 13 Valent For Intramuscular Use 10/21/15. Problem List: Essential hypertension, Cerebral atherosclerosis, Acute ill-defined cerebrovascular disease, Thromboembolic disorder, Pulmonary embolism, Lung disease with systemic sclerosis, I25.119 - Athscl heart disease of native cor art w unsp ang pctrs, Postmenopausal osteoporosis, H/O: pulmonary embolus, Solitary nodule of lung, Myopathy due to rheumatoid arthritis Health Maintenance: EKG - (9/1/2021) Mammogram - (3/5/2021) Bone Density Test - (5/7/2019) Pap Smear - (3/30/2010) Pap Smear - (4/8/2010) EKG - (1/17/2019) PFT - (11/7/2016) Bone Density Test - (3/7/2011) ECHO - (8/23/2013) ECHO - (10/13/2015) EKG - (5/23/2011) EKG - (6/22/2012) EKG - (4/22/2013) EKG - (7/26/2013) EKG - (9/30/2013) EKG - (10/21/2015) EKG - (11/7/2016) Health Care Proxy - (9/9/2020) Husband Advance care planning reviewed with patient and/or caregivers.  Healthcare proxy and MOLST options are reviewed.  Risks and benefits of cardiopulmonary resuscitation, intubation, ventilation, feeding tubes and treatment options in terms of usual medical care are reviewed. Limited medical interventions, and comfort intervention options discussed.  Patient and/or proxy understands that advance directives can be modified as the patient's clinical condition changes.  Office staff assisted in preparation of forms.  Patient would decline CPR, mechanical ventilation, and feeding tube if unable to live independently long-term.  Reviewed and updated without change on December 6, 2021 Bone Density Scan - 2007, 3/2011 OSTEOPENIA  Breast Exam - 6/2012 Pelvic/Pap Exam - (3/2010) , HAS ALL HER FEMALE PARTS AND HAS HX PATERNAL GRANDMOTHER WITH UTERINE CANCER. Declined 6/22/12; counseled to do.  Colonoscopy - counseled 6/22/12 to do counseled, refused. Grandmother with colon cancer Discussed Cologuard testing.  She declines at this time.  Will continue with stool guaiac testing Rectal Exam - 6/22/12 Physical Exam - CPE 6/22/12 EKG - 6/22/12 Childhood Illnesses: Chickenpox, Measles, Mumps Medical Problems: Heel Spur, 4TH RT Nerve Palsy, Fibroadenoma RT Breast, Gastroesophageal Reflux Disease (GERD) Accidents: None Surgical Hx: Tonsillectomy, Carotid Endarterectomy 2013, Lad stent 5/2013 Dr. Hospitalizations: Vaginal Delivery - X3 Assistive Devices: Glasses - (5/20/2019), Bifocal glasses - (5/20/2019) OB/Gyn Hx:Gravidity: (3)Parity: Full Term, 03 Reviewed, no changes. FH: Uterine Cancer - (12/6/2021) PATERNAL GRANDMOTHER Pancreatic Cancer - (12/6/2021) DAD Heart Disease - (12/6/2021) MOM - HEART FAILURE IN HER 90'S Negative For Alcoholism - (12/6/2021) Negative For Drug Addiction - (12/6/2021) Negative For Mental Illness - (12/6/2021). Father: Pancreatic Cancer. Deceased due to Pancreatic Cancer. Mother: Hypertension, Dementia. Deceased due to Hypertension; Dementia. Siblings:3 - (1/17/2019). Reviewed, no changes. SH: Marital: Married.Smoke Free: Home is smoke-free.Education: Highest Level Completed 12th grade.Occupation: Retired.Work Status: retired cafteria worker.Barriers to Care: Social Functioning: None identified - (5/20/2019). Personal Habits:  Tobacco Use: Patient has never smoked - (2/9/2022).Alcohol: Occasionally consumes alcohol - (10/21/2015).Drug Use: Never Used Drugs - (10/21/2015).Daily Caffeine: Consumes on average 2 cups of regular coffee per day - (10/21/2015).Exercise Type: exercises rarely - (10/21/2015) REGULAR AROUND THE HOUSE KIND OF ACTIVITY... (Hygiene)Seat Belt Car: always uses seat belt - (10/21/2015). Reviewed, no changes.   Objective        Ht: 60" Wt: 148lb Wt Prior: 149lb as of 01/21/22 Wt Dif: -1lb BP: 148/78 Pulse: 88 T: 97.9 BMI: 28.9   Exam:  [ ] No acute distress.  HEENT: Pupils equal.  Extraocular movements conjugate.  Dentition normal for age.  Chest: Nontender, normal contour.  Lungs are clear.  No wheezes, rales or rhonchi.  Cardiac distant S1, S2, no rub, gallop.  Abdomen soft, nontender, no mass. Extremities no cyanosis, clubbing, edema  Left fourth fingertip is brownish discoloration, mild tenderness, no erythema.  She has arthritic changes in the fingers without active synovitis  Impression: Overall doing well.  She'll see me back within about a month.