Breast Augmentation Intake

Subjective:
Chief Complaint:
Breast augmentation for modest and natural enhancement.

History of Present Illness:
The patient, Emily Parker, is a 35-year-old female presenting with a desire for breast augmentation. She reports dissatisfaction with the current size and shape of her breasts and expresses a desire for a modest enhancement, aiming for a natural and proportional appearance. She has no prior history of breast surgery. She has a 13-year-old child and does not plan on having more children. She has undergone a mammogram and has a follow-up scheduled in a few weeks. She denies any family history of breast cancer. She reports no history of bleeding disorders, no current tender spots or lumps in her breasts, though she mentions a history of cystic fibroid activity during her menstrual cycle. She has not smoked for the past five years and takes magnesium supplements and lorazepam as needed. She denies being prone to infections or frequent illnesses. Her goal is to achieve a subtle enhancement while maintaining functionality for her active lifestyle.

Past Medical History:
Emily Parker has no significant chronic illnesses or medical conditions reported. She denies any history of bleeding disorders and is not prone to infections or frequent illnesses. She reports a history of cystic fibroid activity during her menstrual cycle but denies any current tender spots or lumps in her breasts.

Family History:
Emily Parker denies any direct family history of breast cancer. No other relevant family history is reported.

Social History:
Emily Parker is self-employed, running a short-term rental business, and leads an active lifestyle, participating in sports regularly. She has not smoked for the past five years and has no plans to have more children.

The Review of Systems:
Constitutional – No fever, chills, weight loss, weight gain, night sweats, fatigue, or weakness.

Eyes – No double vision or blurry vision, wears glasses.

ENT – No hearing loss, dizziness, runny nose, nosebleeds, nasal septum deviation, or sore throat.

Integumentary – No rashes, dry skin, or eczema.

Cardiovascular – No chest pain, heart palpitations, or dizziness.

Respiratory – No shortness of breath, no cough, no wheezing.

Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness or lethargy.

Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.

Genito Urinary – No dysuria, hematuria, frequency, or urgency.

Musculoskeletal – No joint tenderness, redness, or swelling.

Neurological – No headaches or weakness, no history of seizures.

Psychology – No changes in mood, no anxiety.

Hematology – Denies easy bruising.

Past Surgical History:
Emily Parker has no prior history of breast surgery. No other surgical history is reported.

Current Medications:
Emily Parker takes magnesium supplements and lorazepam as needed. She reports no other current use of medications.

Allergies:
Emily Parker has no known allergies.

Objective:
Vital Signs:
Blood Pressure: Not assessed
Heart Rate: Not assessed
Respiratory Rate: Not assessed
Temperature: Not assessed
SpO2: Not assessed

Physical Examination:
Breast/Affected area – Examination reveals excellent skin quality with no abnormalities. Measurements include external notch-to-nipple distances of 21.5 cm on the left and 20 cm on the right, midline-to-nipple distances of 9 cm bilaterally, and a chest circumference of 75 cm. Breast base width is 11 cm bilaterally. Inframammary fold-to-nipple distances are 6 cm bilaterally. No tenderness, lumps, or masses were noted. Minor prominence in the left upper chest wall was observed but deemed insignificant.

General – Appears well, no obvious discomfort.

ENT – No cervical lymphadenopathy, throat normal with no erythema or exudates.

Cardiovascular – Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no jugular venous distension, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.

Respiratory – Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.

Skin – No rashes, no dry skin, no skin infections.

Abdomen – Normal bowel sounds, abdomen soft and nontender, no distension.

Musculoskeletal – No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.

Neurological – Alert and oriented in time, space, and person, normal gait, strength 5/5 in upper and lower limbs, cranial nerves 2-12 grossly intact, coordination intact.

Assessment:
Differential Diagnosis:
1. Cosmetic dissatisfaction with breast size and shape: Based on Emily Parker's expressed concerns and goals for a modest enhancement.
2. Potential asymmetry: Minor prominence in the left upper chest wall noted during examination, though deemed insignificant.
3. History of cystic fibroid activity: Mentioned as a past issue during menstrual cycles but not currently present.

Impression:

• Emily Parker is a 35-year-old female presenting for an initial consultation regarding breast augmentation. 
• She desires a modest enhancement to achieve a natural and proportional appearance while maintaining functionality for her active lifestyle. 
• The patient has no prior history of breast surgery, no diagnosis of bleeding disorders, and no current tender spots or lumps, though she has a history of cystic fibroid activity during her menstrual cycle. 
• Physical examination reveals excellent skin quality, symmetrical breast base width of 11 cm bilaterally, and no significant abnormalities aside from minor prominence in the left upper chest wall. 
• Measurements include an external notch-to-nipple distance of 21.5 cm on the left and 20 cm on the right, with a midline-to-nipple distance of 9 cm bilaterally. 
• The patient has been counseled on implant placement options, incision types, and implant materials, including the pros and cons of saline versus silicone gel implants. 
• She has also been informed about potential risks, complications, and the need for future monitoring or revision surgeries. 
• The patient demonstrates a clear understanding of the procedure and its implications and will consider the provided information before making a final decision.

Problem:

1. Emily Parker presents for a breast augmentation consultation. She expresses dissatisfaction with the current size and shape of her breasts and desires a modest enhancement to achieve a natural and proportional appearance. No other significant issues were identified during the examination.

Plan:

• Procedure: Emily Parker is considering breast augmentation with a preference for a moderate-sized implant. Options discussed include saline versus silicone implants, with placement below the muscle (submuscular) being favored due to her thin breastbone and minimal upper pole thickness. The inframammary fold incision was identified as the preferred approach. Implant sizes in the range of 300 to 325 cc were discussed, with emphasis on achieving a natural and proportional result.
• Follow-up: Emily Parker will review the provided educational materials and return for a second consultation or phone discussion to finalize decisions. A 3D imaging simulation will be conducted to assist in implant size and shape selection.

Surgical Discussion:
A detailed discussion of the breast augmentation procedure, including:

- Purpose of the surgery: The goal is to enhance breast size and shape modestly, achieving a natural and proportional appearance while maintaining functionality for an active lifestyle.
- Alternatives: Alternatives to surgery were not explicitly discussed, as Emily Parker is focused on proceeding with breast augmentation.
- Risks and complications: Emily Parker was informed of potential risks, including hematoma, seroma, bleeding, scarring, infection, capsular contracture, changes in sensation, and pain. Long-term considerations, such as the likelihood of future revision surgeries, were also discussed.
- Anesthesia: General anesthesia will be used. Emily Parker was informed of the associated risks.
- Postoperative care: Postoperative care instructions, including wound care, activity restrictions, and management of drains if applicable, were reviewed.
- Recovery: Recovery expectations include returning to light activities within one to two weeks, avoiding heavy lifting for approximately six weeks, and a gradual return to full activity.