Transition of Care Document

Patient Mary Joan Berns Preferred Language en
Date of birth September 6, 1958 Sex Female
Race Unspecified

Ethnicity Unspecified
Contact info Primary Home:

15986 71st NW

South Haven, MN 55382, US

Tel (Mobile): +1(320)-492-7404

Mail: Mary.berns@gmail.com

Patient IDs 529948 2.16.840.1.113883.3.3710.999.44.88800115636.7770000101

8583 2.16.840.1.113883.3.3710.3

Ellkay 2.16.840.1.113883.3.3710.200.501

8583 2.16.840.1.113883.3.3710.200.500

Document Id test-id-343378867 2.16.840.1.113883.3.3710.0
Document Created: April 5, 2024, 13:45:46 +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 4599844 2.16.840.1.113883.3.3710.999.44.88800115636.7770000111
Encounter Date  From January 30, 2024
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, 13:45:46 +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 Unspecified

Problems

Problem Code Type Status Date of Diagnosis Date of Resolution
Localized obesity (disorder) 270486005(SNOMED) Diagnosis active 01/30/2024
Arthritis (disorder) 3723001(SNOMED) Problem active
Autoimmune disease (disorder) 85828009(SNOMED) Problem active
Circulatory care for venous insufficiency (regime/therapy) 386238003(SNOMED) Problem active
Easy bruising (finding) 424131007(SNOMED) Problem active
Hearing loss (disorder) 15188001(SNOMED) Problem active
Hypothyroidism (disorder) 40930008(SNOMED) Problem active
Lipedema (disorder) 234102003(SNOMED) Problem active
Lymphedema of lower extremity (disorder) 403385000(SNOMED) Problem active

Allergies

Substance RxNorm Reaction(s) Severity Status Start Date
No Known Allergies N/A N/A N/A N/A N/A

Medications

Medication Generic Name RxNorm Strength Strength Unit Route Dose Dose Form Frequency Date Started Date Ended Status Indication Sig
liothyronine liothyronine 903456 5 mcg Oral tablet active
Synthroid levothyroxine 966191 125 mcg Oral tablet active
Wegovy semaglutide (weight loss) 2554104 2.4 mg/0.75 mL Subcutaneous pen injector active

Instructions

Results

No data

History of Procedures

Code Site Date Diagnosed Status
Documentation of past medical history (procedure) completed
Documentation of past medical history (procedure)

Vital Signs

Vital Sign Measurement Date Recorded
Body Height 66.0 in Tue Jan 30 19:13:00 UTC 2024
Body Weight 196.0 lbs Tue Jan 30 19:13:00 UTC 2024
Body Mass Index 31.6 kg/m2 Tue Jan 30 19:13:00 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 skin disorder (situation) - none 161560005 FINDING
Hearing loss (disorder) 15188001 FINDING
Lipedema (disorder) 234102003 FINDING
Arthritis (disorder) 3723001 FINDING
Circulatory care for venous insufficiency (regime/therapy) 386238003 FINDING
Lymphedema of lower extremity (disorder) 403385000 FINDING
Hypothyroidism (disorder) 40930008 FINDING
Easy bruising (finding) 424131007 FINDING
Acquired lymphedema of lower extremity (disorder) 609376003 FINDING
Autoimmune disease (disorder) 85828009 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 01/30/2024 19:00:00 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 65 year old female who is being seen for a lipedema consultation for lipedema affecting the legs, thighs, arms, abdomen, buttocks, and hip shelf. Legs: - Location: Anterior and Posterior - Tenderness: Yes - Bruising: Yes - Pain: Yes - Cuffing: Yes - Dimpling: Yes Thighs: - Location: Anterior and Posterior - Tenderness: Yes - Bruising: Yes - Pain: Yes - Dimpling: Yes Arms: - Tenderness: Yes - Lipomas: I don’t know what that is. - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Abdomen: - Tenderness: Yes - Lipomas: I don’t know what that is. - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Buttocks: - Tenderness: Yes - Lipomas: I don’t know what that is. - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Hip Shelf: - Tenderness: Yes - Lipomas: I don’t know what that is. - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Duration: 45 years Associated Diagnoses: Lymphedema, Venous Disease, and Hashimoto's thyroid disease Similarly Affected Family Members: grandmother and daughter Pedicures: Yes (patient is not able to tolerate pedicure massages) Do You Wear Boots: No Lipedema Worsened By: puberty, pregnancy, and menopause Swelling Occurs With: standing, sitting, and end of day Previous Treatments: Elevation (no change), Manual Lymphatic Drainage for 12 weeks or more (no change), Diet (Mediterranean (no change), Keto (no change), Calorie Restriction (no change), Intermittent fasting (no change), Low Carb (no change), Fasting (no change), and Anti-inflammatory (no change)), and Medication (Semaglutide (Ozempic/Wegovy)) Difficulty Walking: Yes Flexibility: Moderately Flexible Easy Bruising: legs, thighs, abdomen, and arms Pain: when touched (Lowest Pain: 10 out of 10) 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 some difficulty Ability to do chores such as vacuuming or yard work: With a little difficulty Ability to push open a heavy door: Without any difficulty Ability to exercise for an hour: With some difficulty Ability to carry a heavy object (over 10 pounds /5 kg): Without any difficulty Ability to stand up from an armless straight chair: With some 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. Additional History: I have arthritis. My doctor wants to treat me for restless leg syndrome but I told her it’s the lipedema. I would love to go for a walk without pain. I have hypothyroidism. I also have hyperhydrosis so wearing compression is not appealing to me. I get regular lymphatic drainage massages. I need vein surgery as well.

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
Jaime Schwartz Doctor 1336397660 240 S La Cienega Blvd Ste 200, Beverly Hills, CA 902113324, US 3108825454

History And Physical Notes

No data