Transition of Care Document

Patient Rose Christine Averill Preferred Language en
Date of birth October 26, 1961 Sex Female
Race Unspecified

Ethnicity Unspecified
Contact info Primary Home:

2140 longbow lane

clearwater, FL 33764, US

Tel (Mobile): +1(727)-424-3402

Tel (Work Place): +1(727)-447-3000

Mail: raverill@stfrancismed.com

Patient IDs 534416 2.16.840.1.113883.3.3710.999.44.88800115636.7770000101

13096 2.16.840.1.113883.3.3710.3

Ellkay 2.16.840.1.113883.3.3710.200.501

13096 2.16.840.1.113883.3.3710.200.500

Document Id test-id-981168816 2.16.840.1.113883.3.3710.0
Document Created: April 5, 2024, 09:33:47 +0000
Performer Jaime Schwartz
Author Diana Tagaban, Jaime S. Schwartz, MD
Contact info Work Place:

240 S La Cienega Blvd Ste 200

Beverly Hills, CA 902113324, US

Tel (Work Place): 3108825454

Encounter Id 4647789 2.16.840.1.113883.3.3710.999.44.88800115636.7770000111
Encounter Date  From February 12, 2024
Encounter Participant Kaory Silva
Contact info Work Place:

240 S La Cienega Blvd Ste 200

Beverly Hills, CA 902113324, US

Tel (Work Place): 3108825454

Encounter Participant Jaime Schwartz
Contact info Work Place:

240 S La Cienega Blvd Ste 200

Beverly Hills, CA 902113324, US

Tel (Work Place): 3108825454

Legal authenticator Diana Tagaban signed at April 5, 2024, 09:33:47 +0000
Contact info Work Place:

240 S La Cienega Blvd Ste 200

Beverly Hills, CA 902113324, US

Tel (Work Place): 3108825454

Document maintained by Jaime S. Schwartz, MD
Contact info Work Place:

240 S La Cienega Blvd Ste 200

Beverly Hills, CA 902113324, US

Tel (Work Place): 3108825454

Table of Contents


Social History

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

Problems

Problem Code Type Status Date of Diagnosis Date of Resolution
Localized obesity (disorder) 270486005(SNOMED) Diagnosis active 02/12/2024
Easy bruising (finding) 424131007(SNOMED) Problem active
Gastroesophageal reflux disease (disorder) 235595009(SNOMED) Problem active
History of obesity (situation) 161453001(SNOMED) Problem active
History of lipoma (situation) 16900351000119101(SNOMED) Problem active
History of vasculitis (situation) 472974007(SNOMED) Problem active
Lipedema (disorder) 234102003(SNOMED) Problem active
Rheumatoid arthritis (disorder) 69896004(SNOMED) Problem active
Abdominoplasty and liposuction (procedure) 177252003(SNOMED) Problem active
Weight reduction regimen (regime/therapy) 388976009(SNOMED) Problem active

Allergies

Substance RxNorm Reaction(s) Severity Status Start Date
seasonal plants N/A N/A N/A N/A N/A

Medications

No data

Instructions

Results

No data

History of Procedures

Code Site Date Diagnosed Status
Classical cesarean section (procedure) completed
Hysterectomy (procedure) completed
Documentation of past medical history (procedure) completed
Abdominoplasty and liposuction (procedure)
in 1990's after 2 C-sections
Weight reduction regimen (regime/therapy)
Hysterectomy (procedure)
Documentation of past medical history (procedure)
Classical cesarean section (procedure)

Vital Signs

Vital Sign Measurement Date Recorded
Body Height 67.0 in Mon Feb 12 23:23:00 UTC 2024
Body Weight 310.0 lbs Mon Feb 12 23:23:00 UTC 2024
Body Mass Index 48.5 kg/m2 Mon Feb 12 23:23:00 UTC 2024

Plan of Treatment

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

History of Past Illness

Problem Code Type Status Date of Diagnosis Date of Resolution
History of obesity (situation) 161453001 FINDING
History of lipoma (situation) 16900351000119101 FINDING
Lipedema (disorder) 234102003 FINDING
Gastroesophageal reflux disease (disorder) 235595009 FINDING
Arthritis (disorder) 3723001 FINDING
Easy bruising (finding) 424131007 FINDING
History of vasculitis (situation) 472974007 FINDING
Rheumatoid arthritis (disorder) 69896004 FINDING

General Status

No data

Assessments

1.Lipedema Counseling - Lipedema

Immunizations

No data

Functional Status

No data

Mental Status

No data

Reason for Referral

No data

Encounters

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 02/12/2024 21:30:00 UTC 99202

Review Of Systems

No Data

Goals

No data

Medical Equipment

No data

Health Concerns

No data

History of Present Illness

This is a 62 year old female who is being seen for a lipedema consultation for lipedema affecting the legs, thighs, arms, abdomen, upper abdomen, buttocks, hip shelf, and knees. Legs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Cuffing: No - Dimpling: Yes Thighs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Dimpling: Yes Arms: - Tenderness: Yes - Lipomas: No - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Abdomen: - Tenderness: Yes - Lipomas: No - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Upper Abdomen: - Tenderness: Yes - Lipomas: No - Thickened Tender Subcutaneous Fat: No - 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 - Spongy Adipose Tissue: Yes Duration: 20 years Associated Diagnoses: Lymphedema and Varicose veins Similarly Affected Family Members: mother Pedicures: Yes (patient is able to tolerate pedicure massages) Do You Wear Boots: No Lipedema Worsened By: puberty, pregnancy, oral contraceptive pills, menopause, and hysterectomy Swelling Occurs With: standing, sitting, end of day, and summer Previous Treatments: Elevation (better), Compression Garments for 12 weeks or more (no change), Manual Lymphatic Drainage for 12 weeks or more (no change), Sequential Pumps for 12 week or more (no change), and Diet (Intermittent fasting (better) and Keto (better)) Difficulty Walking: Yes Flexibility: Not Flexible Cooler Areas: thighs and buttocks Easy Bruising: thighs, calves, and buttocks Pain: all the time (Average Pain Score: 10 out of 10) Ability to move a chair from one room to another: With much difficulty Ability to bend down and pick up clothing from the floor: Without any difficulty Ability to to stand for one hour: With some difficulty Ability to do chores such as vacuuming or yard work: With much difficulty Ability to push open a heavy door: With a little difficulty Ability to exercise for an hour: With much difficulty Ability to carry a heavy object (over 10 pounds /5 kg): With some difficulty Ability to stand up from an armless straight chair: With some difficulty Ability to dress yourself, including tying shoelaces and buttoning your clothes: With a little difficulty Ability to able to dry your back with a towel: Without any difficulty Due to the patient's lipedema, they are unable to undergo a necessary surgery by another provider (knee replacement). The patient understands and agrees that they must continue wearing compression garments after their surgery.

Family History

No data

Consultation Notes

No data

Laboratory Narrative

No data

Pathology Narrative

No data

Imaging Narrative

No data

Procedure Notes

No data

Progress Notes

No data

Care Team

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

History And Physical Notes

No data