HISTORY: The patient is a female referred by Dr. Thomas for a nonhealing left great toe wound. She is being taken care of at the Care Center with frequent hyperbaric therapies with no significant change in the wound. She denies diabetes.

Past medical history is complicated for multiple past surgeries including a left femoral-to-popliteal bypass graft performed in approximately 20XX at the University of Utah. She had undergone a cadaveric graft following a vein bypass, which she thinks has failed. On the right thereafter, she underwent a successful femoral-to-distal bypass graft, which is doing well. In 20XX, she underwent a right common iliac artery stent placement as well due Peripheral vascular disease.

PAST MEDICAL HISTORY:
1. Hypertension.
2. Keloids.
3. Peripheral vascular disease.
4. Status post gallbladder surgery.
5. Carpal tunnel surgery.
6. Left carotid endarterectomy.

MEDICATIONS:
1. Blood pressure medication.
2. Pain medication.
3. Coumadin 5 mg every Monday, Wednesday, and Friday, and 2.5 mg on the other days. This has recently been increased due to an INR of 1.8 on XX/09/20XX.
4. Vitamins.

ALLERGIES: SULFA.

SOCIAL HISTORY: She denies alcohol and is a non-smoker .She is married, has five children, and is a nurse.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYMPTOMS: A 14-point review of symptoms is positive for joint pain, back pain, difficulty sleeping. She denies chest pain, shortness of breath, nausea, vomiting, and diarrhea.

PHYSICAL EXAMINATION:
HEIGHT: 5′;4"
WEIGHT: 165 pounds
GENERAL: Very pleasant African-American female in no acute distress.
HEENT: Normocephalic and atraumatic. Extraocular muscles are intact.
LUNGS: Clear to auscultation bilaterally.
CVS: Regular rate and rhythm.
ABDOMEN: Soft, obese, and nontender.
EXTREMITIES: The left foot is wrapped. There is a 1+ common femoral artery pulse with a nonpalpable left common femoral artery pulse.
NEUROLOGIC: Cranial nerves II-XII are grossly intact. Alert and oriented times three.

RADIOLOGIC STUDIES: Formal ultrasound imaging was performed by Dr. Andrews in the office today, which demonstrates a proximal fem-to-popliteal bypass graft. There are slow decreased velocities from the proximal to mid thigh region; however, at the junction of the mid to distal one-third, there is no flow identified in the graft.

MRI of the left foot from IMI dated 0X/08/20XX demonstrates findings consistent with cellulitis involving the great toe. No soft tissue abscess.

IMPRESSION:
A nondiabetic female with a complicated past medical history with bilateral vascular bypass procedures due to PAD performed at the Hospital and now with nonhealing left great toe cellulitis. Occlusion of femoral vascular graft .

PLAN: Given the ultrasound findings in my office today of a patent femoral graft to the mid thigh, which occludes, I will attempt recanalization of this graft, which may require stenting with atherectomy and possible TPA to help improve flow into the distal vessels. We will access the right common femoral artery initially.
The patient is currently on Coumadin and I discussed with Jodi, at Peace Cardiology, that we will discontinue her Coumadin as of today and start her on Lovenox 100 mg subcu once a day starting Saturday through Monday. The patient has been scheduled for Tuesday morning at Bright Memorial Hospital.

All the risks, benefits, complications, and alternative procedures have been thoroughly explained to the patient who is in understanding. I did attempt to contact Dr. Davis; however, he is out of town until Monday. I will discuss my findings with him at that time.

David Kramer, MD
Electronically signed by DAVID KRAMER, MD 1/1/20XX

Q=I am confused here as family history is non-contributory which means no credit to the doctor and Past and Social history was met but for new patient past social and family should be met with each item from all three. As per my understanding History was brief, Exam was comprehensive and PFSH-2 . Anyone can help please?