Transition of Care Document

Code	Activity	Start Date	End Date
266919005 (SNOMED)	Never smoker
Birth Sex	female
Sexual orientation	Don’t Know
Gender identity	Identifies as Female

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	01/24/2024
Acquired lymphedema of lower extremity (disorder)	609376003(SNOMED)	Problem	active
Arthritis (disorder)	3723001(SNOMED)	Problem	active
Autoimmune disease (disorder)	85828009(SNOMED)	Problem	active
Deep venous thrombosis (disorder)	128053003(SNOMED)	Problem	active
Easy bruising (finding)	424131007(SNOMED)	Problem	active
Increased blood pressure (finding)	24184005(SNOMED)	Problem	active
Fibromyalgia (disorder)	203082005(SNOMED)	Problem	active
Gastroesophageal reflux disease (disorder)	235595009(SNOMED)	Problem	active
History of bronchitis (situation)	275528007(SNOMED)	Problem	active
History of obesity (situation)	161453001(SNOMED)	Problem	active
History of pneumonia (situation)	161525004(SNOMED)	Problem	active
History of anemia (situation)	275538002(SNOMED)	Problem	active
History of cellulitis (situation)	472962008(SNOMED)	Problem	active
History of fall (situation)	428942009(SNOMED)	Problem	active
History of orthopedic surgery (situation)	53371000119101(SNOMED)	Problem	active
Hypothyroidism (disorder)	40930008(SNOMED)	Problem	active
Lipedema (disorder)	234102003(SNOMED)	Problem	active
Lymphedema of lower extremity (disorder)	403385000(SNOMED)	Problem	active
Rheumatoid arthritis (disorder)	69896004(SNOMED)	Problem	active
Sleep apnea (disorder)	73430006(SNOMED)	Problem	active
History of clinical finding in subject (situation)	417662000(SNOMED)	Problem	active
History of reduction of breast (situation)	428667005(SNOMED)	Problem	active
Reduction mammoplasty (procedure)	59214008(SNOMED)	Problem	active
Reduction plasty of bilateral breasts (procedure)	265250008(SNOMED)	Problem	active
Acne (disorder)	11381005(SNOMED)	Problem	active
Psoriasis (disorder)	9014002(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
Ceclor	203635	Anaphylaxis	severe	active	01/01/1990
methotrexate	6851	Other: Atypical pneumonia	moderate	active	01/01/2021
Rinvoq	2196895	Other: DVT	moderate	active	01/12/2024
gabapentin	25480	Swelling	moderate	active

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
Reclast	zoledronic acid-mannitol-water	705875	5	mg/100 mL	Intravenous	1	piggyback	qyr	11/01/2022		active	Osteoporosis
Orencia	abatacept		250	mg	IV Infusion			q4week	09/07/2021		active	Rheumatoid Arthritis
ciprofloxacin HCl	ciprofloxacin HCl	197511	250	mg	Oral	2	tablet	bid	03/01/2021		active	Infection Knee Joint
hydroxychloroquine	hydroxychloroquine	979092	200	mg	Oral	1	tablet	bid	09/01/2017		active	Rheumatoid Arthritis
levothyroxine	levothyroxine	966222	75	mcg	Oral	1	tablet	qd			active	Hypothyroidism
metoprolol tartrate	metoprolol tartrate	866924	25	mg	Oral	1	tablet	bid	06/01/2022		active	Tachycardia
prednisone	prednisone	198146	2.5	mg	Oral	1	tablet	qd			active	Rheumatoid Arthritis
Savella	milnacipran	833149	25	mg	Oral	1	tablet	bid			active	Fibromyalgia
spironolactone	spironolactone	313096	25	mg	Oral	1	tablet	qd			active	Hypertension
Mounjaro	tirzepatide	2601758	15	mg/0.5 mL	Subcutaneous	1	pen injector	qwk			active	Obesity

• I counseled the patient regarding the following: Skin care: Treatments include diet, exercise, and compression. If there is associated lymphedema, patients can benefit from manual lymphatic drainage. Liposuction has also been used to treat this condition. Expectations: Lipedema is a chronic condition characterized by excessive fat deposits on the legs, thighs, and buttocks. It can also affect the upper arms. The condition can be painful and can cause easy bruising. The cause is unknown. It may be genetic and because the condition affects almost exclusively women, it has been postulated that hormones may play a role in development of the condition. Contact office if: Lipedema causes pain or discomfort. Lipedema is a chronic disease presenting in women during puberty or other times of hormonal, weight and/or shape change such as pregnancy or menopause, characterized by symmetric enlargement of nodular, painful deposition of inflamed and fibrotic subcutaneous adipose tissue. Lipedema was first named as a medical condition in 1940 at the Mayo Clinic1 and in Germany.2 The diagnosis of lipedema is largely clinical and based on criteria initially established in 1951 by Drs. Wold, Allen and Hines.3 Lipedema starts in the lower extremities leading to circumferential bilateral lower extremity enlargement typically seen extending from the below the umbilicus to the ankles resulting in edema, pain and bruising; with secondary lymphedema, fibrosis and spreading of abnormal tissues to the trunk and arms occurs during later stages. Unfortunately as the lipedema tissue grows, the deep fascia and muscle are also affected reducing the function of the lymphatic pump. Lipedema is a hereditary disease and recently the first mutated gene AKR1C1 was discovered resulting in a slower and less efficient reduction of progesterone to hydroxyprogesterone and increased subcutaneous fat deposition in variant carriers, confirming hormones as important in lipedema.4 Lipedema also clearly manifests as a connective tissue disorder characterized by loss of elasticity in the skin5 and the aorta,6 hypertrophic adipocytes, inflammatory cells, and dilated leaky blood and lymphatic vessels.7, 8 She has lipedema in her legs, arms and trunk that includes nodules and pain in these areas. Her hands, feet, and upper trunk have been spared. She has other signs of lipedema including a negative Stemmer’s sign and abnormal fat pad development, disproportion, pain and dysmobility. She also might be developing early stages of lipo-lymphedema and thus her lipedema needs to be treated.] She has tried conservative measures for many months and while conservative therapies can reduce swelling and pain for a short time, removing the diseased tissue with surgery is necessary to reduce symptoms and progression long-term. Lipedema is distinct from non-lipedema obesity, although some, not all, patients can be obese. The adipose tissue accumulation is bilateral and symmetrical in the extremities, with the feet and hands spared from lipedema fat accumulation unless there is loss of elasticity as in hypermobile Ehlers Danlos where the skin has lost elasticity and fat can grow on the hand (with or without obesity). A hallmark of earlier stages of lipedema is the discrepancy in fatty tissue of the extremities compared to the trunk. This is in contrast to the fat associated with lifestyle-induced obesity, which is usually global and proportionate, affecting the abdomen equal or greater than the hips. Women with lipedema find it difficult to lose weight before a needed surgery or other procedures. There is a significant number of women with lipedema who have failed bariatric surgery because they were already controlling their diet but just not losing weight.9-11 Besides the many painful nodules that women with lipedema have, studies indicate that women with lipedema do not have the muscle strength like people who have non-lipedema obesity, are subject to more injuries and have poorer functional capacity.12 Thus, to improve function and reduce pain, lipedema surgery is recommended.13 References 1. Allen EV, Hines EAJ. Lipedema of the legs: A syndrome characterised by fat legs and orthostatic edema. Proc Staff Meet Mayo Clin. 1940;15:184-187. 2. Moncorps C BG, Herteld F et al. xperimentelle untersuchungen zur frage akrozyanotischer zustandsbilder. Arch Derm Syph. 1940;186:209-215. 3. Wold LE, Hines EA, Jr., Allen EV. Lipedema of the legs; a syndrome characterized by fat legs and edema. Ann Intern Med. 1951;34:1243-1250. 4. Michelini S, Chiurazzi P, Marino V, et al. Aldo-Keto Reductase 1C1 (AKR1C1) as the First Mutated Gene in a Family with Nonsyndromic Primary Lipedema. International Journal of Molecular Sciences. 2020;21:6264. 5. Jagtman BA, Kuiper JP, Brakkee AJ. [Measurements of skin elasticity in patients with lipedema of the Moncorps "rusticanus" type]. Phlebologie. 1984;37:315-319. 6. Szolnoky G, Nemes A, Gavaller H, Forster T, Kemeny L. Lipedema is associated with increased aortic stiffness. Lymphology. 2012;45:71-79. 7. AL-Ghadban S, Cromer W, Allen M, et al. Dilated Blood and Lymphatic Microvessels, Angiogenesis, Increased Macrophages, and Adipocyte Hypertrophy in Lipedema Thigh Skin and Fat Tissue. Journal of Obesity. 2019. 8. Felmerer G, Stylianaki A, Hägerling R, et al. Adipose Tissue Hypertrophy, An Aberrant Biochemical Profile and Distinct Gene Expression in Lipedema. J Surg Res. 2020;253:294-303.:10.1016/j.jss.2020.1003.1055. 9. Bast JH, Ahmed L, Engdahl R. Lipedema in patients after bariatric surgery. Surg Obes Relat Dis. 2016;12:1131-1132. doi: 1110.1016/j.soard.2016.1104.1013. Epub 2016 Apr 1114. 10. Pouwels S, Huisman S, Smelt HJM, Said M, Smulders JF. Lipoedema in patients after bariatric surgery: report of two cases and review of literature. Clin Obes. 2018;8:147-150. doi: 110.1111/cob.12239. Epub 12018 Jan 12225. 11. Pouwels S, Smelt HJ, Said M, Smulders JF, Hoogbergen MM. Mobility Problems and Weight Regain by Misdiagnosed Lipoedema After Bariatric Surgery: Illustrating the Medical and Legal Aspects. Cureus. 2019;11:e5388. doi: 5310.7759/cureus.5388. 12. van Esch-Smeenge J, Damstra RJ, Hendrickx AA. Muscle strength and functional exercise capacity in patients with lipoedema and obesity: a comparative study. Journal of Lymphoedema. 2017;12:27-31. 13. Herbst KL, Kahn LA, Iker E, et al. Standard of care for lipedema in the United States. Phlebology 2021;28(2683555211015887):2683555211015887. [published Online First: 2021/05/30 06:00]

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Code	Site	Date Diagnosed	Status
Replacement of bilateral knee joints (procedure)			completed
Cholecystectomy (procedure)			completed
Documentation of past medical history (procedure)			completed
Operation on brain (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
History of cholecystectomy (situation)			completed
History of bypass of stomach (situation)			completed
Bypass of stomach (procedure)			completed
Total replacement of right knee joint (procedure)			completed
Total replacement of left knee joint (procedure)			completed
History of tubal ligation (situation)			completed
Reduction plasty of bilateral breasts (procedure)
History of reduction of breast (situation)
Reduction mammoplasty (procedure)
Roux-en-Y gastrojejunostomy (procedure)
History of tubal ligation (situation)
Cholecystectomy (procedure)
History of cholecystectomy (situation)
Documentation of past medical history (procedure)
Bypass of stomach (procedure)
Total replacement of left knee joint (procedure)
Total replacement of right knee joint (procedure)
Replacement of bilateral knee joints (procedure)
History of bypass of stomach (situation)
Operation on brain (procedure)

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Future visit PRN - Follow up PRN for: Preoperative Appointment, Discussion of Procedure, Additional Consultation, Preoperative Marking

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Acne (disorder)	11381005	FINDING
Psoriasis (disorder)	9014002	FINDING
Deep venous thrombosis (disorder)	128053003	FINDING
History of obesity (situation)	161453001	FINDING
History of pneumonia (situation)	161525004	FINDING
Fibromyalgia (disorder)	203082005	FINDING
Lipedema (disorder)	234102003	FINDING
Gastroesophageal reflux disease (disorder)	235595009	FINDING
Increased blood pressure (finding)	24184005	FINDING
History of bronchitis (situation)	275528007	FINDING
History of anemia (situation)	275538002	FINDING
Arthritis (disorder)	3723001	FINDING
Lymphedema of lower extremity (disorder)	403385000	FINDING
Hypothyroidism (disorder)	40930008	FINDING
History of clinical finding in subject (situation)	417662000	FINDING
Easy bruising (finding)	424131007	FINDING
History of fall (situation)	428942009	FINDING
History of cellulitis (situation)	472962008	FINDING
History of orthopedic surgery (situation)	53371000119101	FINDING
Acquired lymphedema of lower extremity (disorder)	609376003	FINDING
Rheumatoid arthritis (disorder)	69896004	FINDING
Sleep apnea (disorder)	73430006	FINDING
Autoimmune disease (disorder)	85828009	FINDING

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1.Lipedema Counseling - Lipedema

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Service provided at Jaime S. Schwartz, MD, 240 S La Cienega Blvd Ste 200, Beverly Hills, CA 902113324. Office phone number is 3108825454.

Encounter Diagnosis	Location	Date / Time	Type
Lipedema (E65)	Jaime S. Schwartz, MD	01/24/2024 23:00:00 UTC	99202

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This is a 62 year old female who is being seen for a lipedema consultation for lipedema affecting the legs, thighs, arms, abdomen, pubic area, buttocks, hip shelf, knees, and ankles. Legs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Cuffing: Yes - Dimpling: Yes Thighs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Dimpling: Yes Arms: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Abdomen: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Pubic Area: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Buttocks: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Hip Shelf: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Knees: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes Ankles: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Duration: 40 years Similarly Affected Family Members: mother Pedicures: Yes (patient is able to tolerate pedicure massages) Do You Wear Boots: No Lipedema Worsened By: puberty and menopause Swelling Occurs With: standing, sitting, end of day, and summer Previous Treatments: Compression Garments for 12 weeks or more, Manual Lymphatic Drainage for 12 weeks or more, Sequential Pumps for 12 week or more, and bariatric surgery Difficulty Walking: Yes (legs feel extremely heavy) Flexibility: Very Flexible Cooler Areas: calves and arms Easy Bruising: legs, thighs, calves, abdomen, buttocks, arms, and none Pain: all the time, with movement, when touched, and when sleeping Ability to move a chair from one room to another: Without any difficulty Ability to bend down and pick up clothing from the floor: Without any difficulty Ability to to stand for one hour: With much difficulty Ability to do chores such as vacuuming or yard work: With some difficulty Ability to push open a heavy door: Without any difficulty Ability to exercise for an hour: With a little difficulty Ability to carry a heavy object (over 10 pounds /5 kg): With a little difficulty Ability to stand up from an armless straight chair: Without any difficulty Ability to dress yourself, including tying shoelaces and buttoning your clothes: Without any difficulty Ability to able to dry your back with a towel: Without any difficulty The patient understands and agrees that they must continue wearing compression garments after their surgery.

Family history of cancer of colon (situation) - MOTHER

Family history: Diabetes mellitus in first degree relative (situation) - FATHER, GRANDMOTHER, AUNT

Family history of cirrhosis of liver (situation) - FATHER

Family history of chronic obstructive lung disease (situation) - FATHER

Family history of malignant neoplasm of uterus (situation) - AUNT

Family history: Stomach cancer (situation) - GRANDMOTHER

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Care Team Member Name	Role	Identifier	location	Telecom
Jaime Schwartz	Doctor	1336397660	240 S La Cienega Blvd Ste 200, Beverly Hills, CA 902113324, US	3108825454

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