AI Medical Scribe for Plastic Surgeons

POST-OPERATIVE FOLLOW-UP — WEEK 3 SUBJECTIVE Patient reviewed three weeks following bilateral breast augmentation. Reports steady improvement in discomfort, now requiring simple analgesia only. Describes intermittent tightness across the upper poles, worse in the evenings. No fever, no unilateral swelling, no discharge. Has resumed desk work; not yet returned to exercise as advised. OBJECTIVE Incisions: inframammary, healing well bilaterally, no dehiscence. No erythema, no collection, no discharge. Implants: symmetrical position, no evidence of malposition or rippling. Capsule: soft bilaterally, Baker grade I. Sensation: intact to light touch, nipple sensation preserved. ASSESSMENT Uncomplicated recovery at three weeks. Upper pole tightness consistent with expected oedema and muscle adaptation rather than early capsular contracture. PLAN 1. Continue supportive garment for a further three weeks. 2. Commence scar massage once incisions fully epithelialised. 3. Gradual return to cardiovascular exercise from week four; no upper body resistance work until week six. 4. Review at three months with photographs. 5. Patient advised to contact the practice earlier if unilateral swelling, fever or firmness develops.