Primary Clinical Skills: Endocrine/Repro

Documentation Examples of Breasts:

1. Symmetric and smooth without nodules or masses palpated. No nipple discharge. No axillary lymphadenopathy.
2. Pendulous breasts with diffuse fibrocystic changes. Firm, single 1cm x 1cm mobile, nontender mass in upper outer quadrant (11 o’clock), 2 cm from nipple in right breast

Documentation Examples of Female Genitalia:

1. External genitalia with no erythema, lesions, or masses. Pink vaginal mucosa. Parous, pink cervix with no discharge. Uterus anterior, midline, smooth, not enlarged. No adnexal tenderness. Rectovaginal wall intact. No masses felt in rectal vault. No inguinal adenopathy. Pap smear obtained. Stool brown and negative for fecal blood.
2. External genitalia with no erythema, lesions, or masses. Vagina and cervix with thin, white discharge, fishy odor present. No visible discharge visible in cervical os after swab. Uterus anterior, midline, smooth, not enlarged. No adnexal tenderness. Rectovaginal wall intact. No masses felt in rectal vault. Bilateral inguinal adenopathy. Pap smear obtained. Stool brown and negative for fecal blood. Vaginal discharge pH >4.5.

Documentation Examples of Male Genitalia:

1. No penile lesions or discharge, circumcised. No scrotal swelling or discoloration. Smooth testes descended bilaterally, no masses felt. Nontender epidyidymis. No inguinal or femoral hernias. No inguinal adenopathy.
2. No penile lesions or discharge, uncircumcised, prepuce easily retractable. No scrotal swelling or discoloration. Testes descended bilaterally, 1cm x 1cm firm nodule in right medial testicle, smooth left testicle. Nontender epidyidymis. No inguinal or femoral hernias. No inguinal adenopathy.

Documentation Examples of Anus/Rectum/Prostate:

1. No perirectal lesions, warts, discharge, fissures. Intact external sphincter tone. Rectal vault without masses. Brown stool, no fecal blood.
   Male: Prostate smooth, nontender with palpable median sulcus.
   Female: Nontender uterine cervix.
2. Inflamed perirectal area, no lesions, ulcerations, warts, fissures, discharge. Marked inflammation and tenderness of anal canal. External sphincter spasm; unable to examine sphincer, rectal vault, or prostate.
3. No perirectal lesions, warts, discharge, fissures. Intact external sphincter tone. Rectal vault without masses. Left lateral prostate lobe with 1cm x 1 cm firm, hard nodule, right lobe smooth, median sulcus obsure. Brown stool, no fecal blood.