Botox Consult

CC: wrinkles

HPI: *** presents today complaining of facial rhytids. The patient reports having botox in the past in the upper face, the last treatment was approximately 6 months ago.

PMH: ***

PSH: ***

Meds: ***

Allergies: ***

SH: ***

ROS: good exercise tolerance, no chest pain, shortness of breath, coughing, wheezing, palpitations

PE

Gen: NAD, AAOx3

Head: NC AT

Eyes: EOMI b, sclera white

Ears: normal external appearance, EAC clear

Nose: nares patent

Throat: normal oropharyngeal tone, tonsillar pillars symmetric, Mallampati I

Skin: Glogau ***, Fitzpatrick ***, *** rhytids at glabella and forehead, *** crow’s feet on animation

Assessment: *** with facial rhytids.

Plan:

- Botox injection: 20 units procerus/corrugator, 20 units frontalis, 20 units lateral orbicularis

- performed today

- patient tolerated procedure well

- ice pack and post-operative instructions given

- f/u in 2 weeks to assess

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