DIALOGUE

[doctor] patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 .
[doctor] hey , how are you ?
[patient] good . how are you ?
[doctor] i'm doing well . it's good to see you . how have you been ?
[patient] i've been doing good .
[doctor] great . how about your breasts , are they doing all right ?
[patient] great .
[doctor] are you having any chills , fever , nausea , or vomiting ?
[patient] no .
[doctor] good . all right . let's take a peek real quick .
[patient] sure .
[doctor] how's life otherwise ? pretty good ? nothing new ?
[patient] no , just enjoying summertime .
[doctor] okay . how's your family ?
[patient] they're good .
[doctor] good . all right . i'm going to take a look at your breast now . if you would just open up your gown for me .
[doctor] everything looks good .
[patient] yeah .
[doctor] how's your back pain ?
[patient] i'm not really having any more .
[doctor] any hard spots , lumps , or bumps that you've noticed ?
[patient] i did when i came in last time when i saw your pa , ruth sanchez in march . she said i , she said she found a lump right here under my left breast , but i have n't felt it since then . but i did the massages .
[doctor] okay , well . that that's good . uh , it's probably just the scar tissue , but everything looks good and you're healing wonderful , so .
[patient] i told her that the scars here was kind of bothering me and i got scar gel . i was using it everyday , but i do n't think i need it now .
[doctor] yeah , that scar did widen a little bit . let me take a closer look , hang on . this one widened a little too , ? the incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned .
[patient] yeah , but this one just bothered me a little bit more .
[doctor] i understand . um , you can close your gown now .
[doctor] the only thing that is really going to help out that is to uh , to cut it out and re-close it .
[patient]
[doctor] and you do n't want that , ?
[patient] i mean , not right now .
[doctor] um , you want to come back and revisit um , maybe six months ?
[patient] yeah , i will do that . i still have n't , i still have some more of the gel and i can try using that again .
[doctor] okay . keep doing that twice a day . the gel is going to lighten the color a little bit , which is already pretty light . um , but , just in that area , and it's high tension , so it's going to rub a little bit .
[patient] yeah , but it kind of bothers me a little bit .
[doctor] uh , i do see that . like i said , the only way to really fix that is to cut it out .
[patient] uh- .
[doctor] um , let's take a look in six months and then we'll go from there . sound like a plan ?
[patient] but we have n't hit a full year yet .
[doctor] i know . um , i would n't do any revisions anyway for scar tissue until we're at least a year out anyway .
[patient] okay .
[doctor] so let's wait those six months . you can keep using uh , the mederma scar gel twice a day . massage and scar gel will help for the scars . um , you can put it on other scars too , if you need .
[patient] okay .
[doctor] um , so that's what i would do . let's just get some pictures today so we can keep up um , with them . and keep an eye on these scars and then we'll go from there .
[patient] sounds good .
[doctor] all right , well it's good to see you . i'm glad you're doing well .
[patient] yeah , same here .
[doctor] all right . well , i'm going to tell the front desk six months and we'll revisit those scars .
[patient] all right .
[doctor] thank you . they're gon na come get your photos now , okay ?
[patient] okay .

CLINICAL NOTE

CHIEF COMPLAINT

Follow up bilateral reduction mammoplasty.

HISTORY OF PRESENT ILLNESS

Pamela Cook is a 36-year-old female who is returning for a postoperative visit. Status post bilateral reduction mammaplasty 10/10/2020.

The patient was last seen in clinic by Ruth Sanchez, PA in 03/2021 at which time there was a lump along the left breast, and she was advised to perform massages.

Today, Ms. Cook reports she is doing well and that her breasts feel great. She is no longer suffering from back pain. The left breast lower incisional lump from last visit has resolved with massaging and use of scar gel. She reports that the scar on her breast has been bothersome. The patient denies fever, chills, nausea, or vomiting.

CURRENT MEDICATIONS

Mederma scar gel to incision.

PHYSICAL EXAM

Breast
Bilateral breast incisions well healed with widening of the scar tissue. No signs of infection or erythema.

ASSESSMENT

 Status post bilateral reduction mammoplasty.

Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally.

PLAN

- Obtain bilateral breast photos today to monitor scarring.
- Continue Mederma scar gel and incisional scar massage twice daily.

INSTRUCTIONS

Follow up in 6 months to reevaluate scars.