Transition of Care Document

Code	Activity	Start Date	End Date
8517006 (SNOMED)	Former smoker
Birth Sex	female
Sexual orientation	Straight (Heterosexual)
Gender identity	Identifies as Female

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	09/01/2023
Adverse anesthesia outcome (finding)	405656000(SNOMED)	Problem	active
Anxiety (finding)	48694002(SNOMED)	Problem	active
Arthritis (disorder)	3723001(SNOMED)	Problem	active
Attention deficit hyperactivity disorder (disorder)	406506008(SNOMED)	Problem	active
Autoimmune disease (disorder)	85828009(SNOMED)	Problem	active
Cannabis abuse (disorder)	37344009(SNOMED)	Problem	active
Celiac disease (disorder)	396331005(SNOMED)	Problem	active
Deep venous thrombosis (disorder)	128053003(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
Fibromyalgia (disorder)	203082005(SNOMED)	Problem	active
Functional visual loss (disorder)	313165001(SNOMED)	Problem	active
Hearing loss (disorder)	15188001(SNOMED)	Problem	active
History of anemia (situation)	275538002(SNOMED)	Problem	active
History of fall (situation)	428942009(SNOMED)	Problem	active
History of lipoma (situation)	16900351000119101(SNOMED)	Problem	active
History of syncope (situation)	674191000119109(SNOMED)	Problem	active
Hypothyroidism (disorder)	40930008(SNOMED)	Problem	active
Lipedema (disorder)	234102003(SNOMED)	Problem	active
Sexual abuse (event)	213017001(SNOMED)	Problem	active
Victim of sexual abuse (finding)	225826001(SNOMED)	Problem	active
Victim of verbal abuse (finding)	225825002(SNOMED)	Problem	active
Vulvodynia (disorder)	238968009(SNOMED)	Problem	active
Blepharoplasty of bilateral upper eyelids (procedure)	20321003(SNOMED)	Problem	active
Acne (disorder)	11381005(SNOMED)	Problem	active
History of hay fever (situation)	161524000(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
codeine	2670	Nausea, Fatigue, Hives, Rash, Headache	unspecified	active
Sulfa (Sulfonamide Antibiotics)		Swelling, Shortness of Breath, GI upset, Rash, Dizziness, Fatigue, Hives, Diarrhea, Headache, Nausea	unspecified	active
Aleve	215101	Anaphylaxis	unspecified	active
tetracycline	10395	Nausea, Hives, Diarrhea, GI upset, Dizziness, Swelling, Shortness of Breath, Rash, Headache, Fatigue	unspecified	active
Demerol	282381	Nausea, Other: Syncope, Fatigue, Dizziness	unspecified	active

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
clindamycin phosphate	clindamycin phosphate	309332	1	%	Topical		gel				active	acne
tretinoin	tretinoin	313450	0.01	%	Topical		gel				active	acne
Kenalog	triamcinolone acetonide	1085752	10	mg/mL	Injection		suspension				active	Allergies, Chronic Pain
Armour Thyroid	thyroid (pork)	208544	120	mg	Oral		tablet	daily			active	Hashimotos/Hypothyroid
Fioricet	butalbital-acetaminophen-caff	1432261	50-300-40	mg	Oral		capsule	PRN			active	migraines
furosemide	furosemide	310429	20	mg	Oral		tablet				active	edema
Percocet	oxycodone-acetaminophen	1049640	5-325	mg	Oral		tablet				active	chronic pain
potassium citrate	potassium citrate	199381	10	mEq (1,080 mg)	Oral		tablet extended release				active	edema
tizanidine	tizanidine	485485		mg	Oral		capsule	PRN			active	chronic pain

• 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
Classical cesarean section (procedure)			completed
Documentation of past medical history (procedure)			completed
History of total excision of urinary bladder (situation)			completed
Hysterectomy (procedure)			completed
Gastric sleeve (physical object)			completed
Blepharoplasty of bilateral upper eyelids (procedure)
Hysterectomy (procedure)
Documentation of past medical history (procedure)
History of total excision of urinary bladder (situation)
Gastric sleeve (physical object)
Classical cesarean section (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
History of hay fever (situation)	161524000	FINDING
Deep venous thrombosis (disorder)	128053003	FINDING
Hearing loss (disorder)	15188001	FINDING
History of lipoma (situation)	16900351000119101	FINDING
Fibromyalgia (disorder)	203082005	FINDING
Sexual abuse (event)	213017001	FINDING
Victim of verbal abuse (finding)	225825002	FINDING
Victim of sexual abuse (finding)	225826001	FINDING
Lipedema (disorder)	234102003	FINDING
Vulvodynia (disorder)	238968009	FINDING
History of anemia (situation)	275538002	FINDING
Functional visual loss (disorder)	313165001	FINDING
Depressive disorder (disorder)	35489007	FINDING
Arthritis (disorder)	3723001	FINDING
Cannabis abuse (disorder)	37344009	FINDING
Celiac disease (disorder)	396331005	FINDING
Ehlers-Danlos syndrome (disorder)	398114001	FINDING
Adverse anesthesia outcome (finding)	405656000	FINDING
Attention deficit hyperactivity disorder (disorder)	406506008	FINDING
Hypothyroidism (disorder)	40930008	FINDING
Easy bruising (finding)	424131007	FINDING
History of fall (situation)	428942009	FINDING
Anxiety (finding)	48694002	FINDING
History of syncope (situation)	674191000119109	FINDING
Familial multiple lipomatosis (disorder)	766888002	FINDING
Autoimmune disease (disorder)	85828009	FINDING

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1.Lipedema Counseling - Lipedema

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Advised to stop taking Furosimide. Has extensive stretch marks on abdomen. Vulvadinia Since 2000: Sometimes experiences swelling and pain, previous PCP gave DX. Dr. Schwartz suggested vaginismus treatment. Has been in PT for 3 years after 1 hour of kayaking.

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	09/01/2023 20:00:00 UTC	99202

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This is a 53 year old female who is being seen for lipedema follow-up lipedema affecting the legs, thighs, arms, forearms, abdomen, buttocks, hip shelf, knees, and ankles. Since their last visit the lipedema is spreading. Legs: - Location: Anterior and Posterior Thighs: - Location: Anterior and Posterior Forearms: - Tenderness: No - Lipomas: No - Thickened Tender Subcutaneous Fat: No - Spongy Adipose Tissue: No - Cuffing: 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 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 Ankles: - Tenderness: Yes - Lipomas: No - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Duration: 42 years Associated Diagnoses: Lymphedema, Ehlers Danlos, Blood Clots/DVT, Varicose veins, Lipomas, Connective Tissue Disease, and Hashimoto's thyroid disease Similarly Affected Family Members: mother and grandmother Pedicures: No Do You Wear Boots: No Lipedema Worsened By: puberty, pregnancy, oral contraceptive pills, and menopause Swelling Occurs With: standing, sitting, end of day, and summer Previous Treatments: Elevation (50/50), Compression Garments for 12 weeks or more (no change), Manual Lymphatic Drainage for 12 weeks or more (Helpful for legs only), and Diet (Keto (no change), Calorie Restriction (no change), Low Carb (Did carb cycling), and Anti-inflammatory (no change)) Difficulty Walking: Yes Flexibility: Very Flexible Cooler Areas: legs and arms Easy Bruising: legs, thighs, calves, abdomen, buttocks, and arms Pain: all the time (Average Pain Score: 4 out of 10), with movement (Worst Pain: 11 out of 10), when touched (Lowest Pain: 8 out of 10), and when sleeping Ability to move a chair from one room to another: With some difficulty Ability to bend down and pick up clothing from the floor: Without any difficulty Ability to to stand for one hour: Unable to do Ability to do chores such as vacuuming or yard work: With much difficulty Ability to push open a heavy door: With much difficulty Ability to exercise for an hour: Unable to do Ability to carry a heavy object (over 10 pounds /5 kg): With some difficulty Ability to stand up from an armless straight chair: Unable to do Ability to dress yourself, including tying shoelaces and buttoning your clothes: With some difficulty Ability to able to dry your back with a towel: With some difficulty The patient understands and agrees that they must continue wearing compression garments after their surgery. Additional History: Add to Medical History: MTHFR Wilson’s Disease

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Care Team Member Name	Role	Identifier	location	Telecom
Natalie Umbert	Practice Manager		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

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