Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Noticeable changes on the penis (lump, discoloration, ulceration)
Bleeding from the penis
Pain or itching in the penis
Difficulty retracting foreskin (phimosis)
Any recent risky sexual practices (unprotected intercourse, HPV infection)
Past medical history (relevant conditions like sexually transmitted infections)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
Inspection of the penis for:
Lesions (location, size, color, induration)
Prepuce (foreskin) mobility (phimosis)
Inguinal lymph node enlargement
Documentation of glans penis appearance (circumcised or uncircumcised)
Assessment
Suspicion of penile cancer based on clinical presentation
Consider differential diagnoses (balanitis, psoriasis, pearly penile papules)
Plan
Diagnostic tests (depending on presentation):
Biopsy of the penile lesion for definitive diagnosis
Imaging studies (chest X-ray, CT scan, MRI) to assess for lymph node involvement and distant spread
Blood tests (complete blood count, PSA) to evaluate overall health
Referral to a urologist for further management
Education
Importance of biopsy for diagnosis
Explain treatment options based on stage and grade of cancer (if diagnosed) which may include:
Surgery (circumcision, partial penectomy, or total penectomy)
Radiation therapy
Chemotherapy
Laser therapy (in some cases)
Follow-up
Schedule for next appointment:
Discuss biopsy results (if available)
Plan definitive treatment if cancer is confirmed
Schedule for surveillance if negative biopsy
Note: This is a template and may need to be modified based on the individual patient’s presentation and suspected stage of cancer.
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 penile cancer.