Breasts bilaterally symmetrical, no skin dimpling or retraction. No palpable masses or tenderness. No lymph node abnormalities or enlargement on the axillary region. No lesion or nipple discharge: Mental Status and Nervous System, Breast, Abdominal, and Genitourinary.

Soft, non-distended, no rigidity or rebound. Bowel sounds are normoactive in all quadrants upon auscultation. No tenderness, organomegaly, or palpable masses.

No discharge or lesions on external genitalia. No active bleeding or masses noted. No signs of trauma or irritation. No foul smell, vaginal mucosa appears normal.

No masses or prolapses noted. The uterus is normal size and shape, and mildly tender. Adnexa without significant tenderness or palpable masses.

Alert and oriented x3. Muscle strength 5/5 bilaterally in upper and lower extremities.

Reflexes 2+ and symmetric. Sensation intact to light touch. No focal deficits observed. Normal gait and coordination.

Appropriate affect. Well cooperative and engaged during the exam. No signs of depression, anxiety, or other mood disorders.

The thought process is logical and coherent. No hallucinations, delusions, or suicidal ideation.

Inspection should focus on the breast shape, skin change, and nipple, including discharge. The next step is to palpate the entire breast with the patient lying down to check for any masses.

Use a lubricated speculum to inspect the vaginal walls and cervix. Palpate the uterus and conduct a rectovaginal exam if needed to check for masses in the posterior uterus.

Since cancer diagnosis is complicated and physical exams may not lead to a conclusive diagnosis (American Cancer Society, 2025), the use of decision support systems such as Breast Imaging Reporting and Data System (BI-RADS) may improve diagnostic reasoning through risk and symptoms stratification to guide diagnosis and further actions (Merjane et al., 2024).