Subjective
Date of visit
Reason for visit (e.g., erectile dysfunction, pain, anxiety about size)
History of present illness:
Description of the patient’s concerns (be as specific as possible):
Onset and duration of symptoms
Any changes in sexual function or appearance
Psychological impact (anxiety, self-consciousness)
Past medical history (relevant conditions)
Medications (current medications)
Sexual history (if relevant)
Objective
Vital signs (temperature, heart rate, blood pressure) – only if necessary
Physical exam (if indicated):
General inspection of the penis for any abnormalities (e.g., rash, lesions)
Assessment of penile curvature (if a concern)
Focus on functional aspects: Examine for signs of erectile dysfunction or other conditions affecting sexual function.
Assessment
Identify the patient’s primary concern related to their penis.
Consider differential diagnoses based on the patient’s presentation (e.g., erectile dysfunction, Peyronie’s disease, balanitis).
Avoid stating the penis size or making comparisons to average sizes.
Plan
Address the patient’s specific concerns:
Offer reassurance and education about normal variations in penile size.
Discuss treatment options for any underlying conditions identified during the exam.
Consider referral to a urologist for further evaluation or specialized treatment (if needed).
If anxiety about size is a primary concern:
Discuss the psychological impact and provide resources for addressing body image concerns.
Consider referral to a therapist specializing in sexual health.
Follow-up
Schedule for next appointment:
Monitor response to treatment (if applicable)
Address any ongoing concerns
Note: This template emphasizes open communication and focuses on addressing the patient’s specific needs. Measurements or comparisons to average sizes are not included.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of any concerns related to the penis.