Pediatric Surgery - Post Evaluation Examination

May 09, 2025 Daily

Circumcision and Physical Examination Notes

Circumcision

Definition

Circumcision is the surgical removal of the prepuce (foreskin) of the penis.

Indications

Religious or cultural reasons (e.g., Islam, Judaism)
Phimosis (inability to retract the foreskin)
Paraphimosis (inability to return a retracted foreskin)
Recurrent balanitis or UTIs
Prophylactic HIV/STI prevention (in specific populations)

Contraindications

Hypospadias (prepuce may be needed for surgical repair)
Bleeding diathesis (e.g., hemophilia, thrombocytopenia)
Local infection at the surgical site
Unstable or premature neonate

Complications

Immediate:
- Bleeding
- Pain
- Infection
Delayed:
- Meatal stenosis
- Excessive skin removal
- Adhesions
- Urethral fistula

Types of Circumcision

PlastiBell Method
- Bell device placed between glans and prepuce.
- Foreskin tied and necroses over days, falls off with bell.
Gomco Clamp
- Surgical clamp crushes foreskin and allows clean excision.
Mogen Clamp
- Fast clamp method, but risk of glans injury if not careful.
Surgical Blade/Scissors Technique
- Manual excision with layered closure.

Materials Used

Sterile gloves
Local anesthetic (e.g. lignocaine)
Scalpel or scissors
Surgical clamps (e.g., Gomco, Mogen, Plastibell)
Sutures
Antiseptics (chlorhexidine)
Hemostats, sterile gauze, dressing

Additional Checks During Circumcision

Tongue-tie (ankyloglossia): Can affect breastfeeding/speech. Early detection is crucial.
Undescended Testes (UDT): May warrant urologic referral. Missed UDT risks infertility and malignancy.

Physical Examination Template (with Steps and Detail)

General Examination

Observe: posture, activity level, body habitus.
Assess: level of consciousness, pallor, jaundice, cyanosis, dehydration.
Check: symmetry, facial expressions, skin integrity.
Look for: dysmorphic features, distress signs, cachexia.

Sequence

 flowchart TB;
    %% Overall Examination Flow
    Start[Start Comprehensive Medical Examination] --> Introduction[Introduce Self];
    Introduction --> Consent[Obtain Informed Consent];
    Consent --> Patient_Positioning[Appropriate Patient Positioning];
    Patient_Positioning --> Systematic_Examination[Systematic Cephalo-Caudal Examination];

    %% Detailed Examination Subgraphs
    subgraph Hair_Findings["Hair Findings"]
        Hair --> Hair_Fluffy[Fluffy]
        Hair_Fluffy --> Hair_Hypoalbuminemia[Hypoalbuminemia]
        Hair_Hypoalbuminemia --> Hair_Serum_Albumin[Serum Albumin]
        Hair_Fluffy --> Hair_Malnutrition[Malnutrition]
        Hair_Malnutrition --> Hair_Nutritional_Assessment[Nutritional Assessment]
        Hair --> Hair_Alopecia[Alopecia]
        Hair_Alopecia --> Hair_Patchy[Patchy]
        Hair_Patchy --> Hair_Alopecia_Areata[Alopecia Areata]
        Hair_Alopecia_Areata --> Hair_Scalp_Examination[Scalp Examination]
        Hair_Patchy --> Hair_Tinea_Capitis[Tinea Capitis]
        Hair_Tinea_Capitis --> Hair_Fungal_Culture[Fungal Culture]
        Hair_Alopecia --> Hair_Diffuse[Diffuse]
        Hair_Diffuse --> Hair_Telogen_Effluvium[Telogen Effluvium]
        Hair_Telogen_Effluvium --> Hair_History[History]
        Hair_Diffuse --> Hair_Androgenetic_Alopecia[Androgenetic Alopecia]
        Hair_Androgenetic_Alopecia --> Hair_Hormone_Levels[Hormone Levels]
    end

    subgraph Eyebrows_Findings["Eyebrows Findings"]
        Eyebrows --> Eyebrows_Madarosis[Madarosis]
        Eyebrows_Madarosis --> Eyebrows_Hypothyroidism[Hypothyroidism]
        Eyebrows_Hypothyroidism --> Eyebrows_TSH_T4[TSH and T4]
        Eyebrows_Madarosis --> Eyebrows_Alopecia_Areata[Alopecia Areata]
        Eyebrows_Alopecia_Areata --> Eyebrows_Autoimmune_Markers[Autoimmune Markers]
        Eyebrows_Madarosis --> Eyebrows_Blepharitis[Blepharitis]
        Eyebrows_Blepharitis --> Eyebrows_Clinical_Diagnosis[Clinical Diagnosis]
    end

    subgraph Eyes_Findings["Eyes Findings"]
        Eyes --> Eyes_Pallor[Pallor]
        Eyes_Pallor --> Eyes_Anemia[Anemia]
        Eyes_Anemia --> Eyes_Hemoglobin[Hemoglobin]
        Eyes_Pallor --> Eyes_Shock[Shock]
        Eyes_Shock --> Eyes_Blood_Pressure[Blood Pressure]
        Eyes --> Eyes_Jaundice[Jaundice]
        Eyes_Jaundice --> Eyes_Liver_Disease[Liver Disease]
        Eyes_Liver_Disease --> Eyes_LFTs[Liver Function Tests]
        Eyes_Jaundice --> Eyes_Hemolysis[Hemolysis]
        Eyes_Hemolysis --> Eyes_Bilirubin[Bilirubin Levels]
    end

    subgraph Nose_Findings["Nose Findings"]
        Nose --> Nose_Deformities[Deformities]
        Nose_Deformities --> Nose_Trauma[Trauma]
        Nose_Trauma --> Nose_Imaging["Imaging (X-ray, CT)"]
        Nose_Deformities --> Nose_Congenital[Congenital Abnormalities]
        Nose_Congenital --> Nose_Clinical_Diagnosis[Clinical Diagnosis]
        Nose_Deformities --> Nose_Infections["Infections (e.g., Syphilis)"]
        Nose_Infections --> Nose_Serology_Syphilis[Serology for Syphilis]
        Nose_Deformities --> Nose_Tumors[Tumors]
        Nose_Tumors --> Nose_Biopsy[Biopsy]
    end

    subgraph Mouth_Findings["Mouth Findings"]
        Mouth --> Mouth_Hydration[Hydration]
        Mouth_Hydration --> Mouth_Dry[Dry]
        Mouth_Dry --> Mouth_Dehydration[Dehydration]
        Mouth_Dehydration --> Mouth_History_Hydration[History of Fluid Intake]
        Mouth_Dry --> Mouth_Mouth_Breathing[Mouth Breathing]
        Mouth_Mouth_Breathing --> Mouth_History_Mouth_Breathing[History]
        Mouth_Hydration --> Mouth_Moist[Moist]
        Mouth_Moist --> Mouth_Normal_Hydration[Normal]
        Mouth --> Mouth_Cyanosis[Cyanosis]
        Mouth_Cyanosis --> Mouth_Present_Cyanosis[Present]
        Mouth_Present_Cyanosis --> Mouth_Hypoxia[Hypoxia]
        Mouth_Hypoxia --> Mouth_Oxygen_Saturation[Oxygen Saturation]
        Mouth_Hypoxia --> Mouth_ABG[Arterial Blood Gas]
        Mouth --> Mouth_Buccal_Mucosa[Buccal Mucosa]
        Mouth_Buccal_Mucosa --> Mouth_Thrush[Oral Thrush]
        Mouth_Thrush --> Mouth_Candidiasis[Candidiasis]
        Mouth_Candidiasis --> Mouth_Clinical_Diagnosis_Thrush[Clinical Diagnosis]
        Mouth_Candidiasis --> Mouth_Culture_Thrush[Culture if necessary]
        Mouth_Buccal_Mucosa --> Mouth_Ulcers[Ulcers]
        Mouth_Ulcers --> Mouth_Aphthous[Aphthous Ulcers]
        Mouth_Aphthous --> Mouth_History_Ulcers[History]
        Mouth_Ulcers --> Mouth_Herpes[Herpes Simplex]
        Mouth_Herpes --> Mouth_Viral_Culture[Viral Culture]
        Mouth_Ulcers --> Mouth_Malignancy[Malignancy]
        Mouth_Malignancy --> Mouth_Biopsy[Biopsy]
        Mouth_Buccal_Mucosa --> Mouth_Scurvy[Scurvy]
        Mouth_Scurvy --> Mouth_Vitamin_C_Deficiency[Vitamin C Deficiency]
        Mouth_Vitamin_C_Deficiency --> Mouth_Dietary_History[Dietary History]
        Mouth_Vitamin_C_Deficiency --> Mouth_Serum_Vitamin_C[Serum Vitamin C]
        Mouth_Buccal_Mucosa --> Mouth_Angular_Stomatitis[Angular Stomatitis]
        Mouth_Angular_Stomatitis --> Mouth_Vitamin_B_Deficiency[Vitamin B Deficiency]
        Mouth_Vitamin_B_Deficiency --> Mouth_Blood_Tests_Vitamins[Blood Tests for Vitamins]
        Mouth_Angular_Stomatitis --> Mouth_Iron_Deficiency[Iron Deficiency]
        Mouth_Iron_Deficiency --> Mouth_Iron_Studies[Iron Studies]
        Mouth_Angular_Stomatitis --> Mouth_Fungal_Infection[Fungal Infection]
        Mouth_Fungal_Infection --> Mouth_Culture_Angular[Culture]
        Mouth --> Mouth_Dentition[Dentition]
        Mouth_Dentition --> Mouth_Edentulous[Edentulous]
        Mouth_Edentulous --> Mouth_Note_Edentulous[Note if Present]
    end

    subgraph Lymph_Nodes_Findings["Lymph Nodes Findings"]
        Lymph_Nodes --> LN_Enlarged[Enlarged]
        LN_Enlarged --> LN_Firm_Rubbery[Firm, Rubbery]
        LN_Firm_Rubbery --> LN_Lymphoma[Lymphoma]
        LN_Lymphoma --> LN_Biopsy[Biopsy]
        LN_Enlarged --> LN_Matted[Matted]
        LN_Matted --> LN_TB[Tuberculosis]
        LN_TB --> LN_TB_Tests[TB Tests]
        LN_Enlarged --> LN_Tender[Tender]
        LN_Tender --> LN_Infection[Infection]
        LN_Infection --> LN_Culture[Culture]
    end

    subgraph Hands_Findings["Hands Findings"]
        Hands --> Hands_Creases[Creases]
        Hands_Creases --> Hands_Hyperpigmented_Creases[Hyperpigmented]
        Hands_Hyperpigmented_Creases --> Hands_Addisons[Addison's Disease]
        Hands_Addisons --> Hands_ACTH_Stimulation[ACTH Stimulation Test]
        Hands --> Hands_Eminences[Eminences]
        Hands_Eminences --> Hands_Wasted_Eminences[Wasted]
        Hands_Wasted_Eminences --> Hands_CLD[Chronic Liver Disease]
        Hands_CLD --> Hands_LFTs[Liver Function Tests]
        Hands_Wasted_Eminences --> Hands_Malnutrition[Malnutrition]
        Hands_Malnutrition --> Hands_Nutritional_Assessment[Nutritional Assessment]
        Hands --> Hands_Joints[Joints]
        Hands_Joints --> Hands_Swollen_Joints[Swollen]
        Hands_Swollen_Joints --> Hands_RA[Rheumatoid Arthritis]
        Hands_RA --> Hands_RF_AntiCCP[RF, Anti-CCP]
        Hands_Swollen_Joints --> Hands_OA[Osteoarthritis]
        Hands_OA --> Hands_Xray[X-ray]
    end

    subgraph Fingernails_Findings["Fingernails Findings"]
        Fingernails --> FN_Color[Color]
        FN_Color --> FN_Pale[Pale]
        FN_Pale --> FN_Anemia[Anemia]
        FN_Anemia --> FN_Hemoglobin[Hemoglobin]
        FN_Color --> FN_Blue[Blue]
        FN_Blue --> FN_Cyanosis[Cyanosis]
        FN_Cyanosis --> FN_Oxygen_Saturation[Oxygen Saturation]
        FN_Color --> FN_Yellow[Yellow]
        FN_Yellow --> FN_Jaundice[Jaundice]
        FN_Jaundice --> FN_LFTs[Liver Function Tests]
        Fingernails --> FN_Appearance[Appearance]
        FN_Appearance --> FN_Onychomycosis[Onychomycosis]
        FN_Onychomycosis --> FN_Culture[Fungal Culture]
        FN_Appearance --> FN_Onycholysis[Onycholysis]
        FN_Onycholysis --> FN_Psoriasis[Psoriasis]
        FN_Psoriasis --> FN_Clinical_Diagnosis[Clinical Diagnosis]
        FN_Onycholysis --> FN_Thyroid_Disease[Thyroid Disease]
        FN_Thyroid_Disease --> FN_TFTs[Thyroid Function Tests]
        Fingernails --> FN_Clubbing[Clubbing]
        FN_Clubbing --> FN_Respiratory[Respiratory Causes]
        FN_Respiratory --> FN_Chest_Xray[Chest X-ray]
        FN_Clubbing --> FN_Cardiac[Cardiac Causes]
        FN_Cardiac --> FN_Echo[Echocardiogram]
        FN_Clubbing --> FN_GI[GI Causes]
        FN_GI --> FN_Abdominal_Imaging[Abdominal Imaging]
    end

    subgraph Legs_Findings["Legs Findings"]
        Legs --> Legs_Asterixis[Asterixis]
        Legs_Asterixis --> Legs_Hepatic_Encephalopathy[Hepatic Encephalopathy]
        Legs_Hepatic_Encephalopathy --> Legs_LFTs[Liver Function Tests]
        Legs_Asterixis --> Legs_Uremia[Uremia]
        Legs_Uremia --> Legs_Renal_Function[Renal Function Tests]
        Legs_Asterixis --> Legs_Respiratory_Failure[Respiratory Failure]
        Legs_Respiratory_Failure --> Legs_ABG[Arterial Blood Gas]
        Legs --> Legs_Edema[Pedal Edema]
        Legs_Edema --> Legs_Pitting[Pitting]
        Legs_Pitting --> Legs_Heart_Failure[Heart Failure]
        Legs_Heart_Failure --> Legs_BNP[BNP]
        Legs_Pitting --> Legs_Renal_Disease[Renal Disease]
        Legs_Renal_Disease --> Legs_Renal_Tests[Renal Function Tests]
        Legs_Pitting --> Legs_Liver_Disease[Liver Disease]
        Legs_Liver_Disease --> Legs_LFTs[Liver Function Tests]
        Legs_Edema --> Legs_Non_Pitting[Non-Pitting]
        Legs_Non_Pitting --> Legs_Lymphedema[Lymphedema]
        Legs_Lymphedema --> Legs_Ultrasound[Ultrasound]
        Legs_Non_Pitting --> Legs_Myxedema[Myxedema]
        Legs_Myxedema --> Legs_TFTs[Thyroid Function Tests]
    end

    %% Examination Progression
    Systematic_Examination --> Hair_Findings
    Hair_Findings --> Eyebrows_Findings
    Eyebrows_Findings --> Eyes_Findings
    Eyes_Findings --> Nose_Findings
    Nose_Findings --> Mouth_Findings
    Mouth_Findings --> Lymph_Nodes_Findings
    Lymph_Nodes_Findings --> Hands_Findings
    Hands_Findings --> Fingernails_Findings
    Fingernails_Findings --> Legs_Findings
    Legs_Findings --> Examination_Conclusion[Comprehensive Examination Conclusion]

Vital Signs (Order Matters)

Temperature – Oral/axillary/rectal. Check for fever.
Respiratory Rate – Count for a full minute. Look for rhythm, depth.
Pulse Rate – Radial artery; note rhythm, volume, character.
Blood Pressure – Both arms if necessary. Use proper cuff size.

CNS (Brain)

Level of consciousness: alert, drowsy, unconscious.
Orientation: time, place, person.
GCS score: Eye, verbal, motor.
Note any focal deficits or abnormal posture.
SAMPLE SCENARIO:

"Patient is alert, oriented in time, place, and person. GCS is 15. No focal neurological deficits."

Head & Neck

Inspect scalp, fontanelles (if infant), skull shape.
Palpate for tenderness, masses, lymphadenopathy.
Check eyes: symmetry, pupils, conjunctiva, sclera.
Ears: discharge, position, tympanic membrane (if otoscopy done).
Nose: patency, septal deviation, discharge.
Mouth: tongue, palate, mucosa, dentition.

Chest Wall

Shape: symmetrical, barrel, pectus deformities?
Respiratory movement: equal on both sides?
Trachea: central or deviated?
Tactile fremitus: use ulnar border of hand.
Percussion: resonant (normal), dull (consolidation), hyperresonant (pneumothorax).
Expansion: both hands placed posterolaterally.

Respiratory System

Inspect: respiratory rate and effort.
Palpate: expansion, fremitus.
Percuss: anterior and posterior fields.
Auscultate: breath sounds, adventitious sounds (crepitations, wheezes, rubs).

Cardiovascular System

Inspection: precordial bulge, visible pulsation.
Palpation: apex beat (5th ICS MCL), thrills, heaves.
Auscultation: S1, S2, murmurs (location, radiation, timing).
Peripheral pulses: radial, dorsalis pedis, femoral.
Capillary refill time: should be <2 seconds.

Abdomen

Inspect:
- Umbilicus: flat, everted (e.g. in umbilical hernia), inverted.
- Scars, distention, visible peristalsis or pulsation.
Palpate:
- Light: tenderness, guarding.
- Deep: masses (report location, size, surface, consistency, mobility, tenderness).
Liver: span, tenderness.
Spleen: from RLQ to LUQ.
Kidneys: ballotable or not.
Ascites: shifting dullness, fluid thrill.
Percussion: for organomegaly, bowel gas.
Auscultation: bowel sounds (normal, hypoactive, absent).

Example Report:

A firm, nodular mass is palpated in the right flank extending to the umbilicus, measuring 35 x 40 cm. Liver and spleen not palpable due to mass. No ascites. Bowel sounds are normal active.

DRE (Digital Rectal Exam)

Inspection: perianal area, skin tags, fissures, hemorrhoids.
Tone: normal, increased, decreased.
Palpate: rectal wall masses, prostate in males.
Check: stool presence, color, consistency.

Sample Report:

Good perianal hygiene. Normal resting tone. Rectum contains soft feces. No rectal wall masses.

Extremities (Look, Feel, Move)

Look:
- Muscle wasting, scars, deformities, joint swellings.
Feel:
- Temperature, tenderness, pulses, reflexes, sensation.
Move:
- Passive (tone): resistance to movement.
- Active (power): graded 0–5.

Sample Report:

Good muscle bulk in all extremities. Normal tone. Power 5/5. Reflexes intact. No differential warmth or tenderness.

Back & Spine

Inspect for scoliosis, kyphosis, gibbus, scars, sinuses.
Palpate spine: tenderness, step-offs.
Sensory/motor: check dermatomes, reflexes.

Sample Report:

Normal curvature of spine. No masses or deformities. Neurologically intact in both lower limbs.

Gait

Ask patient to walk: heel-toe, tiptoe, tandem.
Check base, symmetry, arm swing.

Types of Abnormal Gait:

Spastic hemiparetic (e.g., stroke)
Ataxic (cerebellar lesion)
Waddling (muscular dystrophy)
High-steppage (peripheral neuropathy)
Festinating (Parkinson's)

Example Report:

Gait is broad-based and ataxic. Patient veers to the right on tandem walking, suggestive of cerebellar lesion.

CASE STUDY APPLICATIONS & PEARLS

In a child coming for circumcision, always use the opportunity for full examination:
- Check for undescended testes.
- Examine oral cavity for tongue tie.
- Document vital signs and assess for signs of congenital syndromes.