Transition of Care Document

Code	Activity	Start Date	End Date
266919005 (SNOMED)	Never smoker
Birth Sex	female
Sexual orientation	Don’t Know
Gender identity	Unspecified

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	01/29/2024
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	12/15/2023
Disorder of connective tissue (disorder)	105969002(SNOMED)	Diagnosis	active	12/15/2023
Iron deficiency (disorder)	35240004(SNOMED)	Diagnosis	active	12/15/2023
Mast cell disorder (disorder)	397007003(SNOMED)	Diagnosis	active	12/15/2023
Allergic rhinitis (disorder)	61582004(SNOMED)	Diagnosis	active	12/15/2023
Generalized skin eruption caused by drug and medicament (disorder)	200892002(SNOMED)	Diagnosis	active	12/15/2023
Immunodeficiency disorder (disorder)	234532001(SNOMED)	Diagnosis	active	12/15/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	12/15/2023
Lymphedema (disorder)	234097001(SNOMED)	Diagnosis	active	12/15/2023
Peripheral venous insufficiency (disorder)	20696009(SNOMED)	Diagnosis	active	12/15/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	12/15/2023
Hypermobile Ehlers-Danlos syndrome (disorder)	30652003(SNOMED)	Diagnosis	active	12/15/2023
Lymphedema (disorder)	234097001(SNOMED)	Diagnosis	active	12/15/2023
Mast cell disorder (disorder)	397007003(SNOMED)	Diagnosis	active	12/15/2023
Varicose veins of lower extremity (disorder)	72866009(SNOMED)	Diagnosis	active	12/15/2023
Peripheral venous insufficiency (disorder)	20696009(SNOMED)	Diagnosis	active	12/15/2023
Iron deficiency (disorder)	35240004(SNOMED)	Diagnosis	active	12/15/2023
Anxiety (finding)	48694002(SNOMED)	Problem	active
Asthma (disorder)	195967001(SNOMED)	Problem	active
Circulatory care for venous insufficiency (regime/therapy)	386238003(SNOMED)	Problem	active
Depressive disorder (disorder)	35489007(SNOMED)	Problem	active
Easy bruising (finding)	424131007(SNOMED)	Problem	active
Emotional abuse (event)	371773006(SNOMED)	Problem	active
Fibromyalgia (disorder)	203082005(SNOMED)	Problem	active
Functional visual loss (disorder)	313165001(SNOMED)	Problem	active
History of asthma (situation)	161527007(SNOMED)	Problem	active
History of bronchitis (situation)	275528007(SNOMED)	Problem	active
History of depression (situation)	161469008(SNOMED)	Problem	active
History of obesity (situation)	161453001(SNOMED)	Problem	active
History of pneumonia (situation)	161525004(SNOMED)	Problem	active
History of anemia (situation)	275538002(SNOMED)	Problem	active
History of gastritis (situation)	691501000119103(SNOMED)	Problem	active
Lipedema (disorder)	234102003(SNOMED)	Problem	active
Abdominoplasty (procedure)	177250006(SNOMED)	Problem	active
Reduction of batwing arms (procedure)	24298005(SNOMED)	Problem	active
Acne (disorder)	11381005(SNOMED)	Problem	active
Eczema (disorder)	43116000(SNOMED)	Problem	active
History of skin disorder (situation)	161560005(SNOMED)	Problem	active
Ehlers-Danlos syndrome (disorder)	398114001(SNOMED)	Problem	active
Lymphedema of limb (disorder)	439500002(SNOMED)	Problem	active
Lymphedema of lower extremity (disorder)	403385000(SNOMED)	Problem	active
Victim of verbal abuse (finding)	225825002(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
ragweed pollen		Fatigue, Headache	moderate to severe	active	10/15/1994

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
Sudafed Sinus 12Hr Pressr-Pain	naproxen-pseudoephedrine				oral						active
Zyrtec-D	cetirizine-pseudoephedrine	1014583	5-120	mg	Oral		tablet extended release 12 hr				active

• 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
Repair of inguinal hernia (procedure)			completed
History of bypass of stomach (situation)			completed
Documentation of past medical history (procedure)			completed
Bypass of stomach (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Bypass of stomach (procedure)			completed
History of bypass of stomach (situation)			completed
Repair of inguinal hernia (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Documentation of past medical history (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Bypass of stomach (procedure)			completed
History of bypass of stomach (situation)			completed
Repair of inguinal hernia (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Documentation of past medical history (procedure)			completed
Bypass of stomach (procedure)			completed
History of bypass of stomach (situation)			completed
Repair of inguinal hernia (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Documentation of past medical history (procedure)			completed
Bypass of stomach (procedure)			completed
History of bypass of stomach (situation)			completed
Repair of inguinal hernia (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Documentation of past medical history (procedure)			completed
Bypass of stomach (procedure)			completed
History of bypass of stomach (situation)			completed
Repair of inguinal hernia (procedure)			completed
Roux-en-Y gastrojejunostomy (procedure)			completed
Surgical biopsy of skin (procedure)			completed
Documentation of past medical history (procedure)			completed
Abdominoplasty (procedure)
Reduction of batwing arms (procedure)
Roux-en-Y gastrojejunostomy (procedure)
Surgical biopsy of skin (procedure)
Documentation of past medical history (procedure)
Bypass of stomach (procedure)
Repair of inguinal hernia (procedure)
History of bypass of stomach (situation)

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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 skin disorder (situation)	161560005	FINDING
Eczema (disorder)	43116000	FINDING
History of obesity (situation)	161453001	FINDING
History of depression (situation)	161469008	FINDING
History of pneumonia (situation)	161525004	FINDING
History of asthma (situation)	161527007	FINDING
Asthma (disorder)	195967001	FINDING
Fibromyalgia (disorder)	203082005	FINDING
Victim of verbal abuse (finding)	225825002	FINDING
Lipedema (disorder)	234102003	FINDING
History of bronchitis (situation)	275528007	FINDING
History of anemia (situation)	275538002	FINDING
Functional visual loss (disorder)	313165001	FINDING
Depressive disorder (disorder)	35489007	FINDING
Emotional abuse (event)	371773006	FINDING
Circulatory care for venous insufficiency (regime/therapy)	386238003	FINDING
Ehlers-Danlos syndrome (disorder)	398114001	FINDING
Lymphedema of lower extremity (disorder)	403385000	FINDING
Easy bruising (finding)	424131007	FINDING
Lymphedema of limb (disorder)	439500002	FINDING
Anxiety (finding)	48694002	FINDING
History of gastritis (situation)	691501000119103	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	01/29/2024 18:00:00 UTC	99202

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This is a 45 year old female who is being seen for lipedema follow-up lipedema affecting the legs, thighs, arms, forearms, abdomen, upper abdomen, buttocks, hip shelf, knees, and ankles. Since their last visit the lipedema is I’m now experiencing additional symptoms since seeing Dr Herbst in December 2023. My lower back is hurting & I’m having issues with both feet. I was diagnosed with tendinitis (left foot) & bunionette (right foot) by a podiatrist. He indicated the pain was resulting from inflammation.. Legs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Not that I’m aware of. I have numerous nodules covering multiple places on my body. I have a nodule that could possibly be a lipoma on my left buttock. - Bruising: Yes - Pain: Yes - Cuffing: Yes - Dimpling: Yes Thighs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Not that I’m aware of - Bruising: Yes - Pain: Yes - Dimpling: Yes Forearms: - Tenderness: Yes - Lipomas: Not that I’m aware of - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Cuffing: Yes Arms: - Tenderness: Yes - Lipomas: Not that I’m aware of - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Abdomen: - Tenderness: Yes - Lipomas: I’m not sure - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Upper Abdomen: - Tenderness: Yes - Lipomas: Not sure - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Buttocks: - Tenderness: Yes - Lipomas: I believe I do - left side - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Hip Shelf: - Tenderness: Yes - Lipomas: Not sure - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Knees: - Tenderness: Yes - Lipomas: Not sure - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Ankles: - Tenderness: Yes - Lipomas: Not sure - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Duration: 35 years Associated Diagnoses: Lymphedema, Ehlers Danlos, Venous Disease, Varicose veins, Lipedema in the breast tissue (diagnosed by a healthcare provider or yourself), and Connective Tissue Disease Similarly Affected Family Members: mother and aunt Pedicures: No Do You Wear Boots: No Lipedema Worsened By: puberty, oral contraceptive pills, and My lipedema has significantly increased since 2021. I suspect that inflammation has spiked during this time - due to chronic stress & anxiety. Swelling Occurs With: standing, sitting, end of day, and summer Previous Treatments: Elevation (no change), Compression Garments for 12 weeks or more (Temporary pain relief & edema reduction ), Manual Lymphatic Drainage for 12 weeks or more (Temporary pain relief & edema reduction ), Sequential Pumps for 12 week or more (Temporary pain relief & edema reduction ), Diet (Low Carb (Helped with pain - no change with physical symptoms ), Fasting (no change), Keto (Helped with pain - no change with physical symptoms ), Calorie Restriction (no change), Intermittent fasting (no change), Small meals after bariatric surgery (no change), Mediterranean (Helped with pain - no change with physical symptoms ), Anti-inflammatory (I believe it has helped with inflammation, however, no change physically ), and Gastric Bypass (no change)), Medication (Phentermine), and Exercise, vibration plate, acupuncture, mayofascia release treatments, pneumatic pump, vein treatments, gastric bypass Difficulty Walking: Yes (trips easily and Leafs extremely heavy, I do not walk in proper form because I have lobules in between my tight. I’m extremely fatigued & in pain with walking even short distances) Flexibility: Very Flexible Cooler Areas: Feet & hands Easy Bruising: legs, thighs, calves, abdomen, buttocks, and arms Pain: all the time (Average Pain Score: 7 out of 10), with movement (Worst Pain: 8 out of 10), when touched (Lowest Pain: 4 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: With some 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 much 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: With a little difficulty The patient understands and agrees that they must continue wearing compression garments after their surgery.

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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

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