Transition of Care Document

Code	Activity	Start Date	End Date
266919005 (SNOMED)	Never smoker
Birth Sex	female
Sexual orientation	Straight (Heterosexual)
Gender identity	Unspecified

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	02/15/2024
Hypermobile Ehlers-Danlos syndrome (disorder)	30652003(SNOMED)	Diagnosis	active	02/15/2024
Lymphedema (disorder)	234097001(SNOMED)	Diagnosis	active	02/15/2024
Mast cell disorder (disorder)	397007003(SNOMED)	Diagnosis	active	02/15/2024
Disorder of autonomic nervous system (disorder)	15241006(SNOMED)	Diagnosis	active	02/15/2024
Varicose veins of lower extremity (disorder)	72866009(SNOMED)	Diagnosis	active	02/15/2024
Peripheral venous insufficiency (disorder)	20696009(SNOMED)	Diagnosis	active	02/15/2024
Blood chemistry outside reference range (finding)	166318006(SNOMED)	Diagnosis	active	02/15/2024
5,10-Methylenetetrahydrofolate reductase deficiency (disorder)	41797007(SNOMED)	Diagnosis	active	02/15/2024
Psoriasis vulgaris (disorder)	200975007(SNOMED)	Diagnosis	active	02/15/2024
Anxiety (finding)	48694002(SNOMED)	Problem	active
Arthritis (disorder)	3723001(SNOMED)	Problem	active
At high risk for malignant neoplasm of breast (finding)	448731000124102(SNOMED)	Problem	active
Attention deficit hyperactivity disorder (disorder)	406506008(SNOMED)	Problem	active
Autoimmune disease (disorder)	85828009(SNOMED)	Problem	active
Bipolar disorder (disorder)	13746004(SNOMED)	Problem	active
Depressive disorder (disorder)	35489007(SNOMED)	Problem	active
Easy bruising (finding)	424131007(SNOMED)	Problem	active
Ehlers-Danlos syndrome (disorder)	398114001(SNOMED)	Problem	active
Familial multiple lipomatosis (disorder)	766888002(SNOMED)	Problem	active
Family history of breast cancer 2 gene mutation (situation)	431331006(SNOMED)	Problem	active
History of appendicitis (situation)	161532008(SNOMED)	Problem	active
History of appendectomy (situation)	428251008(SNOMED)	Problem	active
History of gastritis (situation)	691501000119103(SNOMED)	Problem	active
History of syncope (situation)	674191000119109(SNOMED)	Problem	active
Hypothyroidism (disorder)	40930008(SNOMED)	Problem	active
Lipedema (disorder)	234102003(SNOMED)	Problem	active
Mast cell disorder (disorder)	397007003(SNOMED)	Problem	active
Pain in female genitalia on intercourse (finding)	81712001(SNOMED)	Problem	active
Sexual abuse (event)	213017001(SNOMED)	Problem	active
Sleep apnea (disorder)	73430006(SNOMED)	Problem	active
History of clinical finding in subject (situation)	417662000(SNOMED)	Problem	active
Abdominoplasty and liposuction (procedure)	177252003(SNOMED)	Problem	active
Circumferential lipectomy (procedure)	442732003(SNOMED)	Problem	active
History of reduction of breast (situation)	428667005(SNOMED)	Problem	active
Nasal septoplasty (procedure)	13529000(SNOMED)	Problem	active
Reduction of batwing arms (procedure)	24298005(SNOMED)	Problem	active
Thigh reduction (procedure)	177256000(SNOMED)	Problem	active
Weight reduction regimen (regime/therapy)	388976009(SNOMED)	Problem	active
Wrist repair (procedure)	119656001(SNOMED)	Problem	active
Psoriasis (disorder)	9014002(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
peach		Anaphylaxis	moderate to severe	active	07/14/2018
gluten	1370781	Rash, GI upset, Swelling, Headache	moderate	active	02/14/1990
lactose	6211	GI upset, Swelling	moderate to severe	active	02/14/1990
corn		GI upset	mild to moderate	active	02/14/2015
levonorgestrel	6373	Shortness of Breath, Rash	moderate to severe	active	02/14/2005
Flexeril	224954	Fatigue, Shortness of Breath, Dizziness	moderate to severe	active	06/14/2016

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
Botox	onabotulinumtoxinA	203279			injection				01/01/2022		active
Adderall	dextroamphetamine-amphetamine	577962	20	mg	Oral		tablet		01/01/2023		active
estrogens-methyltestosterone	estrogens-methyltestosterone	197670	1.25-2.5	mg	Oral		tablet		01/01/2021	10/20/2024	suspended
midodrine	midodrine	993462	10	mg	Oral		tablet		01/01/2017		active
nabumetone	nabumetone	311893	750	mg	Oral		tablet		01/01/2022		active
naltrexone	naltrexone		4.5	mg	Oral		capsule		01/15/2021	10/22/2023	suspended
Prometrium	progesterone micronized	261319	200	mg	Oral		capsule		01/01/2021		active
rizatriptan	rizatriptan	314209	10	mg	Oral		tablet		01/01/2022		active
trazodone	trazodone	856377	50	mg	Oral		tablet		01/01/2023		active
vilazodone	vilazodone	1086778	20	mg	Oral		tablet		01/01/2022		active
Stelara	ustekinumab	853354	45	mg/0.5 mL	Subcutaneous		syringe		01/01/2020		active
CombiPatch	estradiol-norethindrone acet	1251501	0.05-0.25	mg/24 hr	Transdermal		patch, transdermal semiweekly		01/01/2021	01/01/2022	suspended

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Code	Site	Date Diagnosed	Status
History of appendectomy (situation)			completed
History of liver excision (situation)			completed
Hysterectomy (procedure)			completed
Documentation of past medical history (procedure)			completed
Wrist repair (procedure)
Nasal septoplasty (procedure)
Abdominoplasty and liposuction (procedure)
Thigh reduction (procedure)
Reduction of batwing arms (procedure)
Weight reduction regimen (regime/therapy)
History of reduction of breast (situation)
Circumferential lipectomy (procedure)
Hysterectomy (procedure)
History of appendectomy (situation)
History of liver excision (situation)
Documentation of past medical history (procedure)

Vital Sign	Measurement	Date Recorded
Heart Rate	96 /min	Thu Feb 15 15:58:40 UTC 2024
Systolic Blood Pressure	158 mm[Hg]	Thu Feb 15 15:58:40 UTC 2024
Diastolic Blood Pressure	90 mm[Hg]	Thu Feb 15 15:58:40 UTC 2024
Body Temperature	98.4 [degF]	Thu Feb 15 15:58:40 UTC 2024
Body Height	74.0 in	Thu Feb 15 15:58:40 UTC 2024
Body Weight	192.0 lbs	Thu Feb 15 15:58:40 UTC 2024
Body Mass Index	24.6 kg/m2	Thu Feb 15 15:58:40 UTC 2024
SaO2 % BldA PulseOx	70.0 %	Thu Feb 15 15:58:40 UTC 2024

Future visit for 02/15/2025 - Follow up in 1 year

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Psoriasis (disorder)	9014002	FINDING
Bipolar disorder (disorder)	13746004	FINDING
History of appendicitis (situation)	161532008	FINDING
Sexual abuse (event)	213017001	FINDING
Lipedema (disorder)	234102003	FINDING
Depressive disorder (disorder)	35489007	FINDING
Arthritis (disorder)	3723001	FINDING
Mast cell disorder (disorder)	397007003	FINDING
Ehlers-Danlos syndrome (disorder)	398114001	FINDING
Attention deficit hyperactivity disorder (disorder)	406506008	FINDING
Hypothyroidism (disorder)	40930008	FINDING
History of clinical finding in subject (situation)	417662000	FINDING
Easy bruising (finding)	424131007	FINDING
History of appendectomy (situation)	428251008	FINDING
Family history of breast cancer 2 gene mutation (situation)	431331006	FINDING
At high risk for malignant neoplasm of breast (finding)	448731000124102	FINDING
Anxiety (finding)	48694002	FINDING
History of syncope (situation)	674191000119109	FINDING
History of gastritis (situation)	691501000119103	FINDING
Sleep apnea (disorder)	73430006	FINDING
Familial multiple lipomatosis (disorder)	766888002	FINDING
Pain in female genitalia on intercourse (finding)	81712001	FINDING
Autoimmune disease (disorder)	85828009	FINDING

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1.Lipedema 2.Hypermobile Ehlers-Danlos Syndrome 3.Lymphedema 4.Mast cell activation, unspecified 5.Disorder of the autonomic nervous system, unspecified 6.Varicose Vein of Lower Extremity with Edema, Pain, and/or Swelling 7.Chronic Peripheral Venous Insufficiency 8.Other specified abnormal findings of blood chemistry 9.Methylenetetrahydrofolate reductase deficiency 10.Psoriasis

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All recommendations in this note should be evaluated by you and your primary healthcare providers to determine if they are appropriate for you. All supplements can have side effects similar to medications and all ingredients on the supplement package should be assessed by you before taking. This visit was 60 minutes with additional time spent in chart review of our clinical questionnaire and data input into our EMR by the patient, and ordering tests or procedures after the face-to-face portion of the visit, with >50% face-to face time spent counseling on lipedema and other causes of fat tissue growth and possible treatments that may help.

Service provided at Total Lipedema Care - Arizona, 6365 E Tanque Verde Road, Suite 200, Tucson, AZ 857153830. Office phone number is 3108825454. Office fax number is 3107475908.

Encounter Diagnosis	Location	Date / Time	Type
Lipedema (E65) Hypermobile Ehlers-Danlos Syndrome (Q79.62) Lymphedema (I89.0) Mast cell activation, unspecified (D89.40) Disorder of the autonomic nervous system, unspecified (G90.9) Varicose Vein of Lower Extremity with Edema, Pain, and/or Swelling (I83.899) Chronic Peripheral Venous Insufficiency (I87.2) Other specified abnormal findings of blood chemistry (R79.89) Methylenetetrahydrofolate reductase deficiency (E72.12) Psoriasis (L40.0)	Total Lipedema Care - Arizona	02/15/2024 16:00:00 UTC

Provider reviewed on Feb 15, 2024. A complete review of systems was performed. No Problems With Bleeding, No Problems With Healing, No Problems With Scarring (hypertrophic Or Keloid), No Rash, No Immunosuppression, No Hay Fever, No Chest Pain, No Leg Pain With Walking, No Fever Or Chills, No Night Sweats, No Unintentional Weight Loss, No Thyroid Problems, No Sore Throat, No Malocclusion, No Nasal Obstruction, No Blurry Vision, No Abdominal Pain, No Bloody Stool, No Constipation, No Diarrhea, No Difficulty Swallowing, No Bloody Urine, No Genital Discharge, No Joint Aches, No Muscle Weakness, No Neck Stiffness, No Headaches, No Seizures, No Facial Weakness, No Facial Numbness, No Shortness Of Breath, No Wheezing, No Bloody Sputum, No Problems With Snoring, No Anxiety, No Depression, No History Of Abuse, No Suicidality, No Difficulty With Body Image, No Anorexia, And No Bulimia.

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This is a 39 year old female who is being seen for a chief complaint of Lipedema. Patient is seeking a plan of care. Patient reports being diagnosed by Dr. Joseph Larry Feldman.

Additional HPI Comments: Please choose any of the following connective tissue conditions or associated conditions that you are seeking care for: Lipedema What is the name of the physician who diagnosed you? Dr. Joseph Larry Feldman What is the name of your primary care physician? Dr. Ernesto Villegas What is your PCP's phone number? (312) 549-4400 What is your PCP's fax number? (312) 549-4401 When did your condition start or when do you think it started? a. Puberty Have you ever noticed your legs were larger than the rest of your body or larger than people of your same age? At what age? 10 Is your tissue painful? Yes If yes, at what age and/or after what event did the pain start? Advancement into stage 2 more fat tissue pain (previously other symptoms, restless legs, occasional nerve pain, blood pooling, etc) Which areas of the body are you experiencing pain? c. Breasts d. Abdomen f. Lower back g. Front of thighs h. Back of thighs m. Ankles Are there areas of your body that are tender to the touch? If yes, where? a. Upper arms c. Breasts g. Front of thighs h. Back of thighs i. Inner thighs m. Ankles On a comparative pain scale of 1-10 (10 being the most painful), what pain level are you experiencing on a daily basis? 4 / 10 What pain level do you experience on a bad day? 6 / 10 What pain level do you experience on a good day? 3 / 10 Do you experience swelling? Yes If yes, where on the body do you experience swelling? a. Upper arms b. Lower arms c. Breasts d. Abdomen e. Upper back f. Lower back g. Front of thighs h. Back of thighs i. Inner thighs j. Front of calves k. Back of calves l. Inner calves m. Ankles Do you swell more standing for long periods of time? Yes How long (minutes) can you stand without swelling, pain or other issues? e. 21-40 minutes Do you swell sitting for long periods of time? Yes How long can you sit without swelling, pain or other issues? e. 21-40 minutes Do you swell or does your swelling worsen in the heat? Yes Do you elevate your legs to make them feel better? Yes Does any swelling you have resolve with elevation or sleeping overnight? Yes Are there any areas of your body that you don’t lose fat tissue from by diet or exercise? (choose all that apply) a. Upper arms b. Lower arms c. Breasts d. Abdomen h. Abdomen i. Front of thighs j. Back of thighs k. Inner thighs Have you been able to lose weight on an eating plan? Yes Have any of the following medications or supplements been helpful for your signs and symptoms? (Choose any that apply) Adderall/Dextroamphetamine What eating plans have you tried that improved your symptoms, including swelling and pain? Ketogenic Mediterranean Anti-inflammatory Intermittent fasting Low carbohydrate Other What exercise do you do? Walking elliptical, new rebounding/trampoline Do you experience extreme fatigue defined as a lingering tiredness that is constant and limiting; in other words, unexplained, persistent, and relapsing exhaustion. Yes Do you have brain fog? Yes Choose all parts of your body where you have heavy tissue: Upper arms Lower arms Abdomen Upper back Lower back Front of thighs Back of thighs Inner thighs Front of calves Back of calves Inner calves Ankles Do you wear compression garments? Yes How long have you worn compression? > one year What are the benefits of wearing your compression garments? Reduction in swelling Have you tried the following manual therapy: manual lymphatic drainage (MLD) therapy as part of complete decongestive therapy? Yes If you tried MLD, did it improve your symptoms? Yes Have you tried the following manual therapy: Deep tissue therapy such as myofascial release, Rolling, Swedish massage, Thai massage, etc. Yes If you tried deep tissue therapy, did it improve your symptoms? No Do you have an intermittent pneumatic compression (IPC) pump? Yes If you have an IPC pump how often do you use it? A few times a week Which of the following therapies have you tried and received benefit for your symptoms (Choose all that apply): Cavitation therapy Acupuncture Does your physical health interfere with your social activities? Yes What do you do for work? Trying to get disability. Quit years ago due to health (diagnosed EDS heds) Does your physical health interfere with your work? Yes Do you bruise easily? Yes How often do you find bruises on your body? Daily Do you have spider veins? Yes Do you have varicose veins? No Do you have venous insufficiency? No Have you ever had a vein procedure such as injection of detergent or radio frequency ablation or stripping to close one of your veins? No If your veins were ever treated, did your symptoms improve? No Have you ever experienced a blood clot or have been diagnosed with deep vein thrombosis DVT)/pulmonary embolus? No Do you feel hard nodules, lumps, or "grains" under the skin in areas with affected tissue? Yes What areas of your body have nodules, lumps or grains? Upper arms Breasts Abdomen Upper back Lower back Front of thighs Back of thighs Inner thighs Front of calves Back of calves lnner calves Ankles Rate your overall health? Poor What was your highest weight in pounds? 245 post pregnancy What was your lowest weight in pounds? 141 (3 years after pregnancy with lots of work) Have you participated in a supervised weight loss program such as a bariatric surgery program, a weight loss clinic, a supervised dietary program, a nutritionist supervised program, a personal trainer or other? Yes If you participated in a supervised weight loss program, did your affected tissue reduce or did your symptoms improve? No If you have previously had any surgical procedures for your condition, did your symptoms improve after the surgery? Yes Is there any additional information you would like for us to know so we can better care for you? Had 1 Lipo, reduced symptoms but did not eliminate, have EDS, my mom recently diagnosed with breast cancer. She has EDS, PCOS, severe endometriosis, psoriatic arthritis. Recently her mother was diagnosed with breast cancer. Here mother and sister have PALB2. Her own gene panels suggest that she is at risk for cancer. She has the MTHFR mutation. She has C6772 which increases the risk of breast cancer. She had her whole genome completed. She has a mutation in CYP19A1. She has found a correlation of her genes with lipedema and PCOS. She also has adenomyosis. Her cancer screening did not find anything. She was on HRT. She found an article from Al-Ghadban showing that estrogen upregulates an enzyme important in breast cancer. After her lipedema surgery she stopped any estrogen. She was on methyltestosterone, a testosterone cream, multiple estrogens and prometrium progesterone. She is having hot flashes, zero libido for over a year. She is having pain with intercourse even with lubricant. She got a full hysterectomy age 36. She used to be hypothyroid bu she exercised and changed her diet, avoided teflon and now her TSH and free T4 are normal. Free T3 was not tested (ok to get tested for free T3). On August 2020 she had a liver lesion 2.9 x 2.6 cm. On a subsequent check 12/16/2021 they found a focal nodular hyperplasia 3.4 x 2.8 cm. It was a CT abdomen and pelvis. Prior to recent liposuction her liver enzymes were normal. Her liver enzymes have been elevated for years and after the liposuction the enzymes reduced. Her A1C started to increase after the liposuction. Her mother and sister have lipomas on the head and now they have them elsewhere. [Familial multiple lipomatosis is associated with PALB2 mutations] Reducing inflammation is important if you are developing lipomas with PALB2. Watch the lipid panel. Avoid high fat not fat in general - eat good fat.

Family history of diabetes mellitus type 1 (situation) - GRANDFATHER, FATHER

Family history of osteoporosis (situation) - MOTHER

Family history of breast cancer gene mutation in first degree relative (situation) - MOTHER

Family history of endometriosis in first degree relative (situation) - SISTER

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Care Team Member Name	Role	Identifier	location	Telecom
Karen Herbst	Doctor	1114977840	6365 E Tanque Verde Road, Suite 200 Tucson, AZ 857153830, US	3108825454

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