Download MBBS Final Year Surgery Case Presentation Carcinoma Penis Clinical Examination Discussion and Treatment

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PATIENT'S DETAILS

Mr.Babu, 64 years old male from Aminjikarai, Auto driver by occupation belonging to lower middle socioeconomic class

CHIEF COMPLAINTS

• Ulcer in the penis for 2 months

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HISTORY OF PRESENTING ILLNESS

• Patient was apparently normal 2 months back after which he developed ulcer over the penis
• Insidious onset, initially small in size, gradually progressed to attain the present size
• Not associated with pain
• Not able to retract skin over the penis

contd.....

• H/o discharge for the past one week- Serousanguineous discharge which is foul smelling

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• No h/o trauma
• No h/o fever
• No h/o difficulty in passing urine
• No h/o pain while passing urine
• No h/o loss of weight /appetite

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contd........

• No h/o abdominal distension/jaundice
• No h/o bone pain
• No h/o cough with hemoptysis
• No h/o swelling in the inguinal region or elsewhere in the body

PAST HISTORY

• No h/o similar complaints in the past

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• No h/o multiple sexual partners
• No h/o circumcision done
• No h/o Diabetes mellitus, hypertension, asthma, tuberculosis, epilepsy, jaundice, sexually transmitted diseases, cardiovascular diseases
• H/o hospitalization for hernia surgery on right side 30 years back in GRH

PERSONAL HISTORY

• Consumes non veg diet

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• Normal bowel and habits
• Not a smoker
• Consumes alcohol 180ml-3 times a week
• No h/o drug abuse
• No h/o tobacco/betel nut chewing

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FAMILY HISTORY

• No relevant family history

ALLERGY HISTORY

• No h/o allergy to any drug or food

GENERAL EXAMINATION

• Patient is conscious, oriented moderately built and nourished
• No pallor, icterus, cyanosis, clubbing, pedal edema, generalised lymphadenopathy

VITALS

• Pulse rate-76/min, regular in rhythm normal volume and character, no vessel wall thickening, no radioradial / radiofemoral delay, felt in all palpable peripheral vessels

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• Respiratory rate-16/min
• Blood pressure-110/80 mmHg measured in right upper arm in sitting posture
• Temperature-afebrile

LOCAL EXAMINATION

• After getting consent and explaining the procedure to the patient, with a male attender by the side the patient was exposed from midchest to midthigh and was examined in bright light

INSPECTION

• A irregular ulcer of size 5x5cm seen on the dorsum of the shaft of penis

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• Margin-ill defined
• Edges-everted and rolled out
• Floor-necrotic tissue
• Extent-from 4cm from the shaft of penis to the glans
• Serosanguineous discharge present

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• A small oval ulcer of size 1x1cm seen above the lesion 3 cm from the shaft of the penis
• Margins are well defined
• Floor- pale pink in colour
• Surrounding skin edematous
• No pigmentation, scars, sinuses seen

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• Inguinal region: a linear scar of size 6cm present in the right inguinal region which is healthy

PALPATION

• Warmth (+)
• Tenderness (+) present over the lesion and the skin surrounding the skin
• Inspectory findings of site, size, shape, extent are confirmed on palpation
• Bleed on touch

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• Base is indurated
• Glans, prepuce, urethral meatus - not able to find

PALPATION OF INGUINAL LYMPH NODES

• Multiple, bilateral, hard, mobile lymph nodes in the inguinal region
• Largest node - 2x2cm present in the right inguinal region with well defined margins 5cm from the pubic symphysis and 7cm from the anterior superior iliac spine
• Not warm, not tender

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• Node is discrete and mobile, hard in consistency
• Skin over the node-normal and pinchable

• From the level of umblicus to the inguinal region-no other lesions found

OTHER SYSTEM EXAMINATION

• RS- normal vesicular breath sounds heard no added sounds
• CVS- S1,S2 heard no murmurs

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• CNS-no focal neurological deficit
• Abdomen- soft,non-tender,no organomegaly, no palpable mass, no free fluid, hernial orifices are free
• Spine and cranium-normal

DIAGNOSIS

• Carcinoma penis involving shaft of penis with bilateral palpable lymph nodes (Stage III – Jackson's staging)

MANAGEMENT

• Investigations

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BASELINE

1. Blood- total count, differential count, ESR, bleeding time, clotting time, Hb%
2. Blood - sugar
3. Urine-sugar, urea, albumin
4. Chest X-ray
5. ECG

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6. Renal function test
7. Serology – HIV, HBsAg, VDRL

SPECIFIC

1. Edge wedge biopsy
2. Punch biopsy of proliferative growth
3. USG Abdomen

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4. FNAC of lymph node
5. CT abdomen
6. Sentinel node biopsy of cabana

TREATMENT

• Total penectomy with perineal urethrostomy
• Lymph nodes-antibiotics for 4 to 6 weeks -resolves then observe

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• Lymph nodes palpable after antibiotics- bilateral ilioinguinal node dissection