Breast Reduction Intake

Subjective:
Chief Complaint:
Breast reduction consultation for symptomatic macromastia.

History of Present Illness:
Emily Carter is a 54-year-old female presenting with interest in reduction mammoplasty. She reports chronic shoulder and back pain attributed to macromastia, with significant discomfort from bra straps causing shoulder grooving and difficulty with daily activities. She states her current brassiere size is 38H and desires reduction to approximately a D cup. She denies any breast masses, nipple discharge, or recent changes in breast tissue. She reports a history of bilateral breast symmetry with the right breast slightly larger. She has a remote history of a bullet wound to the right breast with retained bullet fragment near the spine, deemed inoperable. She has a history of partial hysterectomy (2015), laparoscopic cholecystectomy (2017), knee surgery (1988), and appendectomy (1998). She denies tobacco use since 2012, no current alcohol or caffeine use, and no pregnancies. Current medications include ibuprofen as needed for pain, metformin for borderline diabetes, and weekly vitamin D supplementation for deficiency. She reports stable weight over the past six months. Family history is notable for colon cancer in her father and stomach cancer in her mother, with no family history of breast cancer. She had a screening mammogram in April of this year, which was unremarkable. She follows with a primary care physician, last seen one month ago, and reports no hypertension or other significant comorbidities. She expresses desire for symptom relief and improved quality of life with breast reduction, and is aware of potential changes in nipple sensation and scarring.

Past Medical History:
Borderline diabetes mellitus, vitamin D deficiency, history of retained bullet fragment near spine, no history of needing a breast biopsy, no high blood pressure, no issues reported during last PCP visit, no thyroid issues.

Family History:
Father with colon cancer, mother with stomach cancer, no family history of breast cancer.

Social History:
Former tobacco use, quit in 2012 with no negligence in smoking cessation, no patches or vaping after cessation. Denies saliniquity in use, denies alcohol use, denies coffee consumption, denies having any kids.

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

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

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

Integumentary – No rashes, dry skin, or eczema.

Cardiovascular – No chest pain, heart palpitations, dizziness.

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

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

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

Genito Urinary – No dysuria, hematuria, frequency, 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.

No history of breast lumps, bumps, or discharges.

Past Surgical History:
Partial hysterectomy (2015), laparoscopic cholecystectomy (2017), right knee surgery (1988), appendectomy (1998).

Current Medications:
Ibuprofen as needed for pain, metformin for borderline diabetes, vitamin D supplementation weekly. No medications except ibuprofen.

Allergies:
No known drug allergies reported.

Objective:
Vital Signs:
Weight: 201 lbs, Height: 5'6", BMI: 32.4. Other vital signs not documented.

Physical Examination:
Breast/Affected area – Breasts overall symmetric, right breast slightly larger than left. Sternal notch to nipple: 39 cm bilaterally. Internipple distance: 29 cm. Breast width: 19 cm bilaterally. Nipple-areola complex: left 7 cm (faded), right 6 cm (faded). Nipple to inframammary fold: left 21 cm, right 22 cm. Nipples ptotic, pointing downward, grade 3. Reporting some sensation loss in nipples. Striae present bilaterally. Scar at base of right breast consistent with prior bullet wound. Vertical incision on abdomen, subcostal incision, and left abdominal incision noted. Some abdominal fullness. No palpable masses, no skin changes, no discharge.

General – Appears well, no obvious discomfort.

Cardiovascular – Heart rate regular, normal capillary refill, no JVD, no central or peripheral cyanosis, no clubbing, no peripheral edema.

Respiratory – normal symmetrical chest expansion.

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

Abdomen – 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, CN 2-12 grossly intact, coordination intact.

Test Results:
Screening mammogram performed April 2025, patient reporting that it is unremarkable. No history of abnormal mammogram results.

Assessment:
Differential Diagnosis:
1. Macromastia (N62): Chronic shoulder and back pain, shoulder grooving, large breast size (38H), symptomatic relief with reduction desired.
2. Musculoskeletal pain (M79.1): Back and shoulder pain may have multifactorial etiology, but symptoms correlate with breast size and bra strap pressure.
3. History of retained bullet fragment: Not currently symptomatic but relevant for surgical planning.

Problem:
Breast reduction consultation for symptomatic macromastia with chronic shoulder and back pain, right breast slightly larger, history of retained bullet fragment near spine.

Plan:
Tests: Request for recent laboratory results including CBC, BMP, HbA1c, thyroid function. Repeat labs if unavailable. Letter of medical clearance from PCP for general anesthesia, need to see mammogram.

Plan:

- Procedure: Planned reduction mammoplasty with free nipple graft technique due to long sternal notch to nipple distance and significant ptosis. Markings and measurements obtained. Anticipate loss of nipple sensation postoperatively.
- Follow-up: Await lab results and PCP clearance prior to scheduling surgery. Further preoperative instructions to be provided.

Impression:

- Emily Carter is a candidate for reduction mammoplasty due to symptomatic macromastia with associated chronic shoulder and back pain, shoulder grooving, and functional impairment. 
- Physical examination revealed significant breast hypertrophy (38H), mild asymmetry with the right breast larger, ptosis with long sternal notch-to-nipple distance, and evidence of prior trauma (scar and retained bullet fragment). 
- desires size D
- No palpable masses, nipple discharge, or skin changes were noted. 
- There is no personal or family hx of breast cancer. 
- Preoperative workup is pending, including laboratory evaluation (CBC, BMP, HbA1c, thyroid function) and a clearance letter from her PCP confirming fitness for general anesthesia. 
- The patient is aware of the surgical plan, including the likely need for free nipple grafting due to excessive ptosis, with resultant loss of nipple sensation. 
- She understands the risks, including potential for persistent back pain, and is agreeable to proceed once preoperative requirements are met. 
- No evidence of acute infection, uncontrolled diabetes, or other contraindications at this time. 
- Referral to PCP for preoperative clearance and laboratory assessment has been initiated.

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

- Purpose of the surgery: To reduce breast volume and alleviate symptoms of macromastia, including shoulder and back pain, and improve quality of life. Target reduction to approximately D cup, with anticipated improvement in shoulder symptoms.
- Alternatives: Non-surgical management (supportive bras, physical therapy, weight loss) discussed; patient desires surgical intervention due to refractory symptoms.
- Risks and complications: Patient informed of risks including hematoma, seroma, bleeding, scarring, infection, changes in nipple sensation (including likely loss with free nipple graft), and pain.
- Anesthesia: General anesthesia planned; risks discussed.
- Postoperative care: Instructions to include wound care, management of dressings, activity restrictions, and follow-up for suture removal and monitoring of graft take.
- Recovery: Recovery timeline reviewed; expectation of initial discomfort, need for wound care, and gradual return to normal activities over several weeks.