[doctor] patient is pamela cook , medical record number is 123546 . she is a 36-year-old female post bilateral reduction mammoplasty on 10/10/2020 . doing well , it's good to see you , how you've been ? [patient] i've been doing good . [doctor] great how about your breasts today , doing alright ? great are you having any chills fever nausea or vomiting now good peak real quick sure how is life otherwise pretty good nothing new just enjoying summertime okay how is your family ? [patient] very good . [doctor] good alright i'm gon na take a look at your breast now if you would just open up your gown for me everything looks good has her back pain i'm not really having any more any hard spots lumps or bumps that you've noticed i did when i came in last time when i saw your pa ruthsanchez 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 echo that that is good is probably just a scar tissue but everything looks good and your healing wonderful so i told her that the scar here was kind of bothering me and i got forgel i was using it every day but i do n't think i needed now yeah , that scar did widen a little bit . lem me take a closer look . hang on . this one widened a little too uh . your incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . but this one just bothered me a little bit more understanding culture gown now the only thing that is really going to help out that is to to cut it out and re close it . [patient] [doctor] and you do n't want that uh ? [patient] i mean not right now . [doctor] you want to come back and revisit maybe 6 months yet ellipta that i still have n't i still have some more of the gel and i can try using that again okay . keep doing that twice a day , the gel is going to lighten the color a little bit which is already pretty light but just in that area and it's 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] i do see that like i said the only way to really fix that is to cut it out with a 6 months and then will go from there semi a plan but we have n't had a full year yet i know 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 6 months , you can keep using the mederma scar gel twice a day , massage and scar gel will help for the scars . you can put it on other scars too if you need . [patient] okay . [doctor] so that's what i would do . let's just get some pictures today , so we can keep up with them and keep an eye on this scars and then we will go from there . [patient] sounds good . [doctor] alright , well it's good to see you , i'm glad you're doing well . [patient] yeah , same here . [doctor] alright , well , i'm gon na tell the front desk 6 months and we'll revisit those scars . [patient] alright . [doctor] thank you . i'm gon na come and get your photos now , okay ? [patient] okay .
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.
