General Plastic Surgery Intake

Subjective:
Chief Complaint:
Mommy makeover consultation, abdominoplasty and breast augmentation with implants.
MRN xxxxxx

History of Present Illness:
Emily Parker is a 41-year-old female presenting for consultation regarding a mommy makeover. She reports primary concerns with her abdomen, specifically excess skin, and expresses interest in both abdominoplasty and breast augmentation with implants. Emily has a history of liposuction and gluteal fat grafting performed in 2023 without complications and is satisfied with the results. She denies any current breast issues, including lumps, masses, or nipple discharge, and has not previously undergone mammography. Her breast size is currently 36C, and she desires breast implants without mastopexy. Emily reports stable weight since her prior surgery. She denies any history of bleeding or clotting disorders, has no history of anesthesia complications, and is not currently taking any medications. She denies nicotine use and reports only occasional alcohol consumption. Her last primary care visit was two to three months ago, with laboratory results reported as normal. Emily’s expectations are to address abdominal excess skin and achieve breast augmentation with implants.

Past Medical History:
Emily Parker denies any problems with anesthesia, denies any history of bleeding or clotting, reports no medical problems, no bleeding or clotting disorders, and has not had any mammograms done previously.

Family History:
No significant family history provided.

Social History:
Emily Parker denies any nicotine use and reports no smoking. She reports occasional alcohol consumption. She works at a fruit store and has support at home.

The Review of Systems:
A negative review of systems. No lumps, bumps, or discharges in the breast.
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, 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.

Past Surgical History:
Emily Parker underwent liposuction and gluteal fat grafting (Brazilian Butt Lift) in 2023 in xxxxxx. She reports no complications and is satisfied with the results.

Current Medications:
No medications.

Allergies:
No allergies reported.

Objective:
Vital Signs:
Height: 5 feet 4 inches. Weight: 187 pounds. Body Mass Index: 32.1. No other vital signs documented.

Physical Examination:
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 distention, 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.
Breast/Affected area – Breasts are relatively symmetric. Right breast is slightly larger than the left. Chest circumference is 38 inches, bust circumference is 43 inches. Sternal notch to nipple distance is 27 centimeters bilaterally. Breast width is 15 centimeters bilaterally. Nipple-areola complex measures 6 centimeters bilaterally. Nipple to fold distance is 10 centimeters bilaterally. Left breast has a tattoo. Left inframammary fold is slightly higher by 0.5 to 1 centimeter. No palpable masses, no skin changes, no nipple discharge. Abdomen shows excess skin. Evidence of prior liposuction. Flanks and bra line with excess skin. No tenderness or distension. Ptosis grade 2.
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 II-XII grossly intact, coordination intact.

Assessment:
Impression:
Emily Parker is a 41-year-old female presenting for evaluation of abdominal excess skin and desire for breast lift. She is status post liposuction and gluteal fat grafting in 2023 without complications. Physical examination reveals abdominal skin laxity and relatively symmetric breasts with mild asymmetry and no palpable masses.

Problem:
1. Abdominal skin laxity following prior liposuction and gluteal fat grafting.
2. Desire for breast augmentation with implants.
3. Mild breast asymmetry.
4. No current breast pathology identified.

Plan:
Tests: Mammogram is recommended prior to any breast procedure. Standard laboratory tests including complete blood count and basic metabolic panel are advised.
Plan: Surgical plan includes extended abdominoplasty (tummy tuck) to address excess abdominal skin, liposuction of the upper back, flanks, bra line, and anterior axillary fold, with Renuvion (J-Plasma) skin tightening for the sides and back. Breast lift, pending normal mammogram results. Anterior axillary fold liposuction is also planned. Incision placement and surgical technique discussed in clinic.
Follow-up: Await mammogram and laboratory results prior to scheduling surgery.

Surgery Discussion:
The planned procedures include extended abdominoplasty, liposuction of the upper back, flanks, bra line, and anterior axillary fold, Renuvion (J-Plasma) skin tightening, and breast lift, measured bra size 38 DD, desires to stay with the same volume just lifted. The purpose of these procedures is to address abdominal skin laxity and enhance breast volume and contour. The need for a mammogram before breast surgery was discussed. Incision placement and the possibility of a breast lift were reviewed. Risks and complications, including bleeding, infection, scarring, asymmetry, and anesthesia-related risks, were discussed. Postoperative instructions and expected recovery were reviewed. No questions for the doctor.