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Discussion Starter · #1 ·
A 68 year old man with long-standing diabetes mellitus type I and an HbA1c of 8%, nephropathy, peripheral neuropathy on all 4 limbs, comes to your office complaining about the presence of a painless ulcer on the shaft of his penis. Upon questioning he reveals that he has sex with prostitutes. Physical exam reveals a painless ulcer with soft borders. Bilateral foot examination reveals complete loss of vibration sense. Before you start any diagnostic procedure, which is the most likely cause of his lesion?

a) Primary syphilis
b) Hemophilus ducreyi
c) Secondary syphilis
d) Trauma
e) Tertiary syphilis
 

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A

I think it's a) Primary Syphilis mainly because he has sex with prostitutes and the others are wrong because:
You "do cry" with H. ducreyi because it causes painful ulcers.
Secondary syphilis doesn't present w ulcers (that's the one with the maculopapular rash on the palms and soles).
Trauma is unlikely unless his loss of sensation has extended that far. Which I don't think happens or does it?
 

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I think it's a) Primary Syphilis mainly because he has sex with prostitutes and the others are wrong because:
You "do cry" with H. ducreyi because it causes painful ulcers.
Secondary syphilis doesn't present w ulcers (that's the one with the maculopapular rash on the palms and soles).
Trauma is unlikely unless his loss of sensation has extended that far. Which I don't think happens or does it?
Chancres in 1ry syphilis have a hard (indurated) base & edges, not soft.
 

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i would go with primary syphillis as an answer over h. ducreyi, despite the fact that it is soft border instead of cartilagenous consistencey of syphilitic ulcer. but since the patient is obviously not impotent, means the neuropathy has not reached the perineal nerves. tertiary syphillis occurs after 20 years approx. after the non treated ulcer. trauma is supposed to be painful. secondary syphillis is maculo papular lesion... so best answer is primary syphilis> h. ducreyi
 

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Going with A

The peripheral neuropathy is normal in diabetics and is already expected.

But the painless ulcer is clear signs of primary s.

I just complated step 1 soo idk if theres a step 2 trick involved here lol.
 

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Discussion Starter · #8 ·
Guys first of all I made up this question so don't be hard on me in case I am wrong:eek::eek::eek: but the correct answer I had in mind is trauma :notsure: Let me tell you my thoughts and let me know if you find them correct.

Syphilis: Painless but hard indurated borders

Chancroid: Soft borders but painful. Diabetic neuropathy could explain loss of sensation but he has sex so he must have intact nerves.

Tertiary syphilis: could explain his proprioceptional symptoms (tabes dorsalis) but the Q asks about the etiology of the ulcer.

Secondary syphilis: No evidence of palmar/pedal rash or condylomata lata on examination

Trauma is the one that fits the most. A superficial trauma is not always painful compared to the chancroid ulcer that is very painful.

Nevertheless, I don't expect that kind of question in the step but I kinda feel it stresses out certain issues that might be important! I.e like the quality of the ulcers and the possibility of a neuropathy that might be masking pain.

As I said, I made up this question and I am not sure 100%. :):)
 

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Well, I thought about trauma too, but I thought it would still hurt to have a wound on the penis. I thought may be he's too diabetic to feel it, but then again, how can he be having sex if the sensations are not intact?

But I think it would work though. May be a tiny ulcer - note that the size of the ulcer was not mentioned - can be painless.

Anyway, good one! I like it :D
 
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