Transition of Care Document

Code	Activity	Start Date	End Date
266927001 (SNOMED)	Unknown if ever smoked
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	07/28/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	05/31/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	04/24/2023
History of orthopedic surgery (situation)	53371000119101(SNOMED)	Problem	active
Lipedema (disorder)	234102003(SNOMED)	Problem	active
Sleep apnea (disorder)	73430006(SNOMED)	Problem	active
Easy bruising (finding)	424131007(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
Sulfa (Sulfonamide Antibiotics)		Rash	unspecified	active

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
Acetaminophen Extra Strength	acetaminophen		500	mg	Oral	600mg	tablet	Q6-8H	05/26/2023		active	for pain	2 Tab PO Q 6-8H for pain
cefadroxil	cefadroxil	309049	500	mg	Oral	500mg	capsule	Q 12H	05/26/2023		active		1 Cap Q 12H X 10 Days
Colace	docusate sodium	1247756	100	mg	Oral	100mg	capsule	Q 8H	05/26/2023		active		2 Cap PO Q 8H until bowel movement
gabapentin	gabapentin	310431	300	mg	Oral	500mg	capsule	Q6-8H	05/26/2023		active	pain	1 Cap Q 6-8H for pain
ibuprofen	ibuprofen	197806	600	mg	Oral	600mg	tablet	Q6-8H	05/26/2023		active	for pain	1PO Q6-8H for pain
ondansetron	ondansetron	312087	8	mg	Oral	8mg	tablet,disintegrating	Q 8HR PRN	05/26/2023		active	nausea	1 Tab sublingual Q 8H PRN nausea
Percocet	oxycodone-acetaminophen	1049640	5-325	mg	Oral	5-325mg	tablet	Q4-6H PRN	05/25/2023		active	pain	1 Tab PO Q 4-6 H PRN for pain
Xarelto	rivaroxaban	1114202	10	mg	Oral	10mg	tablet	daily	05/26/2023		active		Take 1 tablet by mouth daily for 10 days.

• 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
Documentation of current medications (procedure)		10/26/2023	active
Documentation of current medications (procedure)		08/28/2023	active
Documentation of current medications (procedure)		05/31/2023	active
Documentation of past medical history (procedure)			completed
Documentation of past medical history (procedure)			completed
Documentation of past medical history (procedure)			completed
Plastic surgery self-referral (procedure)
Documentation of past medical history (procedure)

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

Code	Detail	Instructions
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
1114202	Xarelto 10 mg tablet	Take 1 tablet by mouth daily for 10 days.
312087	ondansetron 8 mg disintegrating tablet	1 Tab sublingual Q 8H PRN nausea
197806	ibuprofen 600 mg tablet	1PO Q6-8H for pain
310431	gabapentin 300 mg capsule	1 Cap Q 6-8H for pain
1247756	Colace 100 mg capsule	2 Cap PO Q 8H until bowel movement
309049	cefadroxil 500 mg capsule	1 Cap Q 12H X 10 Days
165458	Acetaminophen Extra Strength 500 mg tablet	2 Tab PO Q 6-8H for pain
1049640	Percocet 5 mg-325 mg tablet	1 Tab PO Q 4-6 H PRN for pain

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Lipedema (disorder)	234102003	FINDING
Easy bruising (finding)	424131007	FINDING
History of orthopedic surgery (situation)	53371000119101	FINDING
Sleep apnea (disorder)	73430006	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	07/28/2023 19:30:00 UTC	99212

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This is a 61 year old female who is being seen for a post-op check, to assess healing of the left proximal pretibial region, right anterior proximal thigh, left anterior distal thigh, and right proximal pretibial region. She is following up from LRS- Anterior Legs and Thighs performed on 05/31/2023. She describes wound healing as healed, and pain is moderate in severity. Surgical wounds are healed. She reports that status is better. She feels that symmetry is currently good. She reports being extremely satisfied with the current result. Since first surgery: Mobility, pain, appearance of skin better as well as it not being so sensitive to the touch Recap on first surgery- what was found

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Care Team Member Name	Role	Identifier	location	Telecom
Evyn Escobar	Medical Assistant		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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