What are the pre-operative clearance findings for a 22-year-old female undergoing breast augmentation, with normal laboratory (labs) results, history, and physical examination?

From the Guidelines

The patient is medically cleared for the planned breast augmentation procedure based on normal pre-operative assessment findings, including history, physical examination, and laboratory studies. The decision to clear the patient for surgery is guided by the patient’s clinical history, comorbidities, and physical examination findings, as recommended by guidelines and recommendations for preoperative testing before noncardiac surgery 1.

Pre-operative Assessment

The comprehensive pre-operative assessment conducted on the 22-year-old female patient included:

• A complete history to identify any underlying medical conditions or risk factors
• A physical examination to assess the patient’s overall health and identify any potential issues
• Laboratory studies to evaluate the patient’s blood work and other health indicators

Findings and Recommendations

All findings from the pre-operative assessment were within normal limits, indicating that the patient is in good health with no contraindications to surgery. Based on these results, no specific medications or interventions are required prior to surgery. The patient should follow standard pre-operative instructions, including:

• Fasting for at least 8 hours before surgery
• Avoiding blood thinners like aspirin or NSAIDs for 7-10 days prior to the procedure
• Arranging for transportation home after surgery

Medical Clearance

This medical clearance is valid for 30 days from the date of examination. The normal pre-operative assessment suggests the patient has minimal risk factors for surgical or anesthetic complications, supporting a favorable surgical outcome, as supported by guidelines for preoperative testing before noncardiac surgery 1.

From the Research

Pre-Operative Clearance for Breast Augmentation

The patient, a 22-year-old female, presented for pre-operative clearance for breast augmentation. The following procedures were performed:

• Labs: normal results
• History: normal results
• Physical exam: normal results

Documentation Comment

Based on the studies, the documentation comment for the patient's pre-operative clearance should include:

• Informed consent information, as established by expert consensus, including essential risk items, risk factors, and expectations 2
• Discussion of potential risks and complications, such as capsular contracture, implant rupture, and scarring 3
• Review of the patient's medical history, including any previous surgeries or medical conditions 4
• Explanation of the surgical procedure, including the type of implant to be used and the surgical technique 3
• Discussion of post-operative care and follow-up appointments 3

Patient Education

The patient should be educated on the following topics:

• The risks and benefits of breast augmentation surgery 2, 5
• The potential complications and their management 3, 4
• The importance of follow-up care and appointments 3
• The patient's responsibilities in terms of post-operative care and wound management 3

Informed Consent

The patient's informed consent should be documented, including:

• The patient's understanding of the risks and benefits of the procedure 2, 5
• The patient's decision to undergo the procedure 2, 5
• The patient's acknowledgement of the potential complications and their management 3, 4