PRECIOUS IKHIANOSE AITANUN  ·  CLINICAL JOURNAL
Daily Entry

Pediatric Surgery - Post Evaluation Examination

Daily Serious

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

  1. PlastiBell Method
    • Bell device placed between glans and prepuce.
    • Foreskin tied and necroses over days, falls off with bell.
  2. Gomco Clamp
    • Surgical clamp crushes foreskin and allows clean excision.
  3. Mogen Clamp
    • Fast clamp method, but risk of glans injury if not careful.
  4. 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

Legs Findings
Asterixis
Legs
Hepatic Encephalopathy
Liver Function Tests
Uremia
Renal Function Tests
Respiratory Failure
Arterial Blood Gas
Pedal Edema
Pitting
Heart Failure
BNP
Renal Disease
Renal Function Tests
Liver Disease
Non-Pitting
Lymphedema
Ultrasound
Myxedema
Thyroid Function Tests
Fingernails Findings
Color
Fingernails
Pale
Anemia
Hemoglobin
Blue
Cyanosis
Oxygen Saturation
Yellow
Jaundice
Liver Function Tests
Appearance
Onychomycosis
Fungal Culture
Onycholysis
Psoriasis
Clinical Diagnosis
Thyroid Disease
Thyroid Function Tests
Clubbing
Respiratory Causes
Chest X-ray
Cardiac Causes
Echocardiogram
GI Causes
Abdominal Imaging
Hands Findings
Creases
Hands
Hyperpigmented
Addison's Disease
ACTH Stimulation Test
Eminences
Wasted
Chronic Liver Disease
Liver Function Tests
Malnutrition
Nutritional Assessment
Joints
Swollen
Rheumatoid Arthritis
RF, Anti-CCP
Osteoarthritis
X-ray
Lymph Nodes Findings
Enlarged
Lymph_Nodes
Firm, Rubbery
Lymphoma
Biopsy
Matted
Tuberculosis
TB Tests
Tender
Infection
Culture
Mouth Findings
Hydration
Mouth
Dry
Dehydration
History of Fluid Intake
Mouth Breathing
History
Moist
Normal
Cyanosis
Present
Hypoxia
Oxygen Saturation
Arterial Blood Gas
Buccal Mucosa
Oral Thrush
Candidiasis
Clinical Diagnosis
Culture if necessary
Ulcers
Aphthous Ulcers
History
Herpes Simplex
Viral Culture
Malignancy
Biopsy
Scurvy
Vitamin C Deficiency
Dietary History
Serum Vitamin C
Angular Stomatitis
Vitamin B Deficiency
Blood Tests for Vitamins
Iron Deficiency
Iron Studies
Fungal Infection
Culture
Dentition
Edentulous
Note if Present
Nose Findings
Deformities
Nose
Trauma
Imaging (X-ray, CT)
Congenital Abnormalities
Clinical Diagnosis
Infections (e.g., Syphilis)
Serology for Syphilis
Tumors
Biopsy
Eyes Findings
Pallor
Eyes
Anemia
Hemoglobin
Shock
Blood Pressure
Jaundice
Liver Disease
Liver Function Tests
Hemolysis
Bilirubin Levels
Eyebrows Findings
Madarosis
Eyebrows
Hypothyroidism
TSH and T4
Alopecia Areata
Autoimmune Markers
Blepharitis
Clinical Diagnosis
Hair Findings
Fluffy
Hair
Hypoalbuminemia
Serum Albumin
Malnutrition
Nutritional Assessment
Alopecia
Patchy
Alopecia Areata
Scalp Examination
Tinea Capitis
Fungal Culture
Diffuse
Telogen Effluvium
History
Androgenetic Alopecia
Hormone Levels
Start Comprehensive Medical Examination
Introduce Self
Obtain Informed Consent
Appropriate Patient Positioning
Systematic Cephalo-Caudal Examination
Comprehensive Examination Conclusion

Vital Signs (Order Matters)

  1. Temperature – Oral/axillary/rectal. Check for fever.
  2. Respiratory Rate – Count for a full minute. Look for rhythm, depth.
  3. Pulse Rate – Radial artery; note rhythm, volume, character.
  4. 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.
← All journal entries