Dr Muhammad Sajjad

04/12/2025

Here is a clear, practical, step-by-step guide to circumcision using the Bone Cutter (Gomco-like) method, suitable for clinical learning:

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Circumcision – Bone Cutter Method (Step-by-Step)

1. Preparation

Consent and explain the procedure.

Check age, bleeding history, pe**le anomalies (hypospadias, chordee).

Keep sterile set:
Bone cutter (metal bell + clamp), artery forceps, scissors, scalpel blade, sutures (4-0/5-0 absorbable), lignocaine, povidone-iodine, sterile drapes, gauze.

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2. Anesthesia

Dorsal Pe**le Nerve Block (0.5–1% lignocaine without adrenaline):

Inject at 10 and 2 o’clock positions at the base of the p***s.

Total dose: 0.2–0.4 ml per kg (max safe lignocaine: 3 mg/kg).

Allow 5 minutes for effect.

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3. Cleaning & Draping

Clean with povidone-iodine.

Drape the ge***al area.

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4. Break Preputial Adhesions

Use blunt probe/hemostat to gently separate fo****in from g***s.

Check that the meatus is centrally located.

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5. Apply Bone Cutter (Bell Device)

a. Expose the g***s

Retract the fo****in fully behind the corona.

b. Choose correct size bell

Bell should fit snugly over the g***s, covering it completely.

c. Position the Bell

Place metal bell over the g***s, keeping frenulum protected.

d. Pull fo****in back over the bell

Bring the fo****in forward to completely cover the bell.

e. Apply the Clamp

Place the bone cutter clamp over the fo****in and bell.

Tighten until firmly locked — this crushes the fo****in blood vessels.

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6. Excise the Fo****in

Use a scalpel blade or scissors to cut the fo****in flush along the rim of the bell.

Ensure the cut is even and circular.

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7. Remove the Clamp

After 2–3 minutes, slowly release the clamp.

Remove the bell carefully.

Inspect the g***s.

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8. Hemostasis

Usually adequate due to crushing effect.

If needed, use:

Small pressure with gauze

Monopolar cautery (very minimal)

A single 4-0 absorbable suture at frenulum if bleeding continues.

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9. Dressing

Apply petroleum gauze or antibiotic ointment.

Wrap loosely with sterile gauze.

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10. Post-Procedure Care

Keep the area clean and dry.

Apply petroleum jelly at every diaper change (infants) or 3×/day (older boys).

Oral analgesics: paracetamol.

Return if: bleeding, swelling, fever, difficulty urinating.

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Important Tips

Always ensure correct bell size; too small → injury, too large → bleeding.

Do not cut frenulum too close.

For infants, the bone cutter gives excellent cosmetic results.

If g***s cannot be fully visualized → stop, rule out phimosis or anomaly.

04/12/2025

Umbilical Stump Care

✅ 1. Keep It Dry

Always keep the stump dry.

Fold the diaper below the stump so it does not cover or rub it.

Avoid applying oil, ghee, ash, surma, or powders.

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✅ 2. Clean Only If Dirty

If urine or stool contaminates the stump:

Clean gently with clean water or normal saline.

Pat dry with a clean cloth/gauze.

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✅ 3. Do Not Pull the Stump

It will dry and fall off on its own — usually within 7–10 days.

Do not try to remove it even if it looks like it is hanging.

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✅ 4. Avoid Covering It Too Much

Keep the area exposed to air as much as possible.

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✅ 5. Chlorhexidine Use?

For home births or in areas with poor hygiene:
Apply chlorhexidine 7.1% (delivers 4% CHG) once daily for 7 days.

For clean hospital births: dry cord care is enough.

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When to Suspect Infection (Omphalitis)

Seek medical care if you see:

Redness spreading around the stump

Foul-smelling discharge

Swelling or warmth

Baby becomes lethargic, refuses feeds, or develops fever

🩺 Management of Omphalitis

Omphalitis is a medical emergency in newborns because it can rapidly progress to sepsis.

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✅ 1. Assess Severity

Mild (localized):
Redness limited to the umbilicus, minimal discharge, no systemic symptoms.

Moderate–Severe:
Spreading redness, swelling, purulent discharge, foul smell, fever, lethargy, poor feeding → treat as sepsis.

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✅ 2. Investigations (when moderate/severe)

CBC with differential

CRP

Blood culture

Swab of umbilical discharge for culture

Sepsis screen

If severe: consider LP (lumbar puncture)

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✅ 3. Treatment

A. Mild Local Omphalitis (No systemic signs)

Topical antibiotics:

Mupirocin 2% ointment — apply 3 times daily for 5–7 days

Clean with normal saline; keep dry.

Strict follow-up in 24 hours.

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B. Moderate to Severe Omphalitis (Systemic signs)

Admit immediately. Start IV antibiotics.

First-line IV regimen:

IV Ampicillin + IV Gentamicin

Ampicillin: 50 mg/kg IV every 6–8 hours

Gentamicin: 5 mg/kg IV once daily

If severe cellulitis or foul smell (anaerobes suspected):

Add Metronidazole

Metronidazole 7.5 mg/kg IV every 8 hours

Severe or high-risk cases / MRSA risk:

IV Vancomycin instead of Ampicillin.

Duration:

Mild–moderate: 7–10 days

Severe / systemic infection: 10–14 days

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✅ 4. Supportive Care

Thermoregulation

IV fluids if poor feeding

Monitor vitals 4-hourly

Treat sepsis if indicated

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🚨 Red Flags Requiring Immediate Action

Spreading erythema around the abdomen

Fever, lethargy

Purulent discharge with foul smell

Bleeding from stump

Abdominal wall induration (necrotizing fasciitis → surgical consult)

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🔍 Special Situations

Necrotizing Omphalitis

Rapidly spreading cellulitis

Severe systemic toxicity
→ Emergency surgical referral + broad-spectrum IV antibiotics (Vancomycin + Meropenem).

04/12/2025

Management of Impetigo in Children

1. Identify the Type

Non-bullous impetigo → Most common; honey-colored crusts.

Bullous impetigo → Caused by Staph aureus; large flaccid bullae.

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2. General Measures

Gentle cleansing with warm water.

Remove crusts before applying topical antibiotics.

Avoid sharing towels, clothes, toys.

Keep nails short; maintain good hygiene.

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3. Topical Antibiotics (First-line for limited disease)

Use when lesions are few, localized, and child is otherwise well.

Options

Mupirocin 2% ointment
Apply TDS for 5 days.

Fusidic acid 2% cream
Apply TDS for 5–7 days.

Retapamulin 1% (if available)
Apply BD for 5 days.

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4. Systemic Antibiotics (For extensive disease or bullous impetigo, or if topical fails)

Use when:

Multiple or widespread lesions

Bullous impetigo

Fever or systemic symptoms

Recurrent impetigo

Outbreak setting

First-line

Oral cephalexin
25–50 mg/kg/day divided QID for 7 days.

Alternative options

Amoxicillin–clavulanate
25–45 mg/kg/day divided BD for 7 days.

Cloxacillin
50 mg/kg/day divided QID for 7 days (if staph suspected).

For suspected MRSA

Clindamycin 10–30 mg/kg/day divided TID

Trimethoprim-sulfamethoxazole (Septran)
8 mg TMP/kg/day divided BD
Note: Not effective against Group A strep.

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5. If Recurrent

Check for nasal carriage of Staph aureus.

Mupirocin nasal ointment BD × 5 days.

Improve hygiene practices at home.

Treat close contacts if symptomatic.

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6. When to Refer

No improvement after 3–5 days of appropriate therapy.

Extensive bullous disease.

Signs of systemic infection (fever, lymphadenitis).

Immunocompromised child.

04/12/2025

Here is a clear, practical, clinic-friendly management plan for nocturnal enuresis in children (bedwetting after age ≥5 years):

✅ 1. Initial Assessment

Before treatment, always rule out reversible causes:

History

Frequency: how many wet nights/week

Daytime symptoms: urgency, frequency, dribbling (suggests overactive bladder)

Constipation (very common contributor)

UTI symptoms

Sleep pattern, stressors, family history

Fluid intake (tea, soda, evening fluids)

Examination

Abdomen (constipation), spine exam, ge***alia

Urinalysis (rule out UTI, diabetes mellitus/insipidus)

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✅ 2. First-Line Management (Behavioural Therapy)

Most children respond to these if done consistently for 2–3 months.

Lifestyle & behavioural modifications

Fluid restriction after 6–7 PM

No caffeine/soft drinks in evening

Void before going to bed

Scheduled voiding every 2–3 hours during daytime

Treat constipation aggressively

PEG 3350 (if available), lactulose, high fibre intake

Rewards system: give stars for “attempts,” not dry nights

Avoid

Punishment/shaming

Excessive fluid restriction during day

✅ 3. Enuresis Alarm Therapy (Best long-term success)

Indicated when:

Child is motivated

Parents can supervise nightly

Wetting >2 nights/week

How it works:
A moisture-sensitive alarm wakes the child when urination begins → trains brain-bladder connection.

Duration:

Use for 8–12 weeks

Success rate: 50–70% permanent cure

✅ 4. Pharmacological Treatment

Best for short-term control, sleepovers, exams, or when alarm cannot be used.

A. Desmopressin (DDAVP)

First-line medication

Dose (oral melt/tablet): 0.2 mg at bedtime, may increase to 0.4 mg

Avoid drinking water 1 hour before and 8 hours after taking medicine

Works best in children with:

Normal daytime bladder function

No constipation

No underlying stress

Side effects: rare but can cause hyponatremia if excess water taken.

B. Anticholinergics

(Use only if child has daytime urgency/frequency or overactive bladder.)

Oxybutynin 2.5–5 mg at bedtime

Often combined with desmopressin if single therapy fails.

✅ 5. When Both First-Line and Medications Fail

Refer to pediatric urologist if:

Persistent symptoms after 6 months

Daytime incontinence

Recurrent UTIs

Suspected anatomical/neurological problem

Very small bladder capacity on ultrasound

Quick Structured Plan for Practice

1. Evaluate + Urinalysis

2. Fix constipation + Behavioural therapy (6–8 weeks)

3. If not improved → Enuresis alarm OR Desmopressin

4. If partially improved → Combine alarm + meds

5. Persistent failure → Refer to urology

04/12/2025

02/12/2025

Management of Heck’s Disease (Focal Epithelial Hyperplasia)

Heck’s disease is a benign HPV-associated condition (HPV 13 & 32) that causes multiple, soft, painless papules on the oral mucosa—common in children and young adults.
It is self-limiting in most patients.

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1. Patient Education

Reassure that it is benign, non-cancerous, and often regresses spontaneously within months to a few years.

Explain that lesions are due to HPV types not associated with malignancy.

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2. Observation (First-line)

No active treatment needed if lesions are mild, asymptomatic, and not cosmetically bothersome.

Follow-up every 3–6 months.

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3. Indications for Treatment

Treat only if:

Lesions are large, persistent, or progressively increasing

Causing trauma, biting, bleeding, or speech interference

Cosmetic concerns

Patient preference

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4. Treatment Options

A. Surgical Treatments (Most effective)

1. Excision

For large or isolated lesions.

2. Cryotherapy (liquid nitrogen)

Commonly used; effective for multiple small lesions.

3. CO₂ Laser Ablation

Effective and precise for multiple clustered papules.

4. Electrosurgery

Alternative when laser unavailable.

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B. Medical / Topical Options

Used when surgery not preferred, especially for multiple lesions:

1. Topical Imiquimod 5% cream

Apply 3 times per week until improvement (off-label).

Immunomodulatory and antiviral.

2. Interferon-α injections or topical interferon (rarely used now).

3. Topical Retinoids (0.05% tretinoin)

Applied carefully to individual lesions.

4. Sinecatechins (green tea extract)

Limited data but may help in HPV lesions.

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C. Supportive Care

Maintain good oral hygiene

Avoid trauma/biting

Treat any secondary infection (rare)

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5. Follow-Up

Reassess in 6–12 weeks if treated.

Monitor for recurrence (possible but usually small).

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6. Prognosis

Excellent.

Many cases resolve spontaneously, especially in children.

Malignant transformation does NOT occur.

29/11/2025

A "combi kit" medicine for leucorrhea typically refers to an oral combination therapy containing an antibiotic and an antifungal to treat multiple potential causes of abnormal vaginal discharge. Common examples include kits with secnidazole (an antibiotic), azithromycin (an antibiotic), and fluconazole (an antifungal). These kits are used for syndromic treatment, addressing various bacterial, fungal, and parasitic infections that can cause symptoms like discharge, itching, and discomfort.

27/11/2025

Methotrexate (MTX) remains the anchor drug in Rheumatology — and 2024–2025 guidelines keep it front and centre.

🔹 Weekly dosing (NOT daily)
🔹 Rapid escalation to 20–25 mg/week
🔹 SC route = better absorption
🔹 Folic acid co-medication
🔹 Monitor CBC/LFT/renal q2–4 weeks → q8–12 weeks when stable
🔹 Watch for lung, liver, marrow toxicity
🔹 Contraception required for 3 months (men & women)

MTX + short-term steroids = first-line strategy.
If optimized MTX fails → switch to biologic/tsDMARD.

26/11/2025

EPI SCHEDULE IN CHILDREN

The EPI now covers 12 major vaccine-preventable diseases including TB, polio, diphtheria, pertussis, tetanus, hepatitis B, Hib, pneumonia (PCV), rotavirus, measles, rubella, and typhoid.

If a baby comes for the first time at 8 months, you will do catch-up vaccination.
Below is the correct EPI catch-up schedule for an 8-month-old (Pakistan).

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✅ Catch-Up Vaccination Schedule for an 8-Month-Old (First Visit at 8 months)

➤ Visit 1 (At 8 months / Day 0):

Give all of the following:

Pentavalent-1 (DTP + Hep B + Hib)

PCV-1 (Pneumococcal)

OPV-1

IPV-1

Rotavirus – NOT given (too old; max age is 24 weeks)

MR – NOT yet (MR starts at 9 months)

TCV – NOT yet (Typhoid starts at 9 months)

BCG only if there is no BCG scar and child is below 1 year

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➤ Visit 2 (After 4 weeks – at 9 months):

Give:

Pentavalent-2

PCV-2

OPV-2

MR-1 (now age ≥9 months)

TCV (Typhoid Conjugate Vaccine)

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➤ Visit 3 (After 4 weeks – at 10 months):

Pentavalent-3

PCV-3

OPV-3

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➤ Visit 4 (At 15 months):

MR-2 (at least 4 weeks after MR-1)

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⭐ Important Notes

Never restart the schedule — just continue with minimum intervals.

BCG can be given up to 12 months in EPI if no scar and child is healthy.

Rotavirus cannot be given after 24 weeks (6 months).

PCV must complete 3 doses even if started late (

26/11/2025

Developmental milestonss and Anthropometric measures in children

26/11/2025

Here is clear, practical, and safe management of scabies in children:

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🧒 Management of Scabies in Children

✅ 1. First-Line Treatment

Permethrin 5% Cream (Preferred)

Safe for children ≥ 2 months.

Apply from neck to toes, including:

Between fingers/toes

Under nails

Groin, buttocks

Belly button

Armpits

Leave for 8–12 hours, then wash off.

Repeat after 1 week (mandatory to kill newly hatched mites).

Infants (15 kg, single dose 200 mcg/kg, repeat after 1 week.

Useful if:

Severe/crusted scabies

Outbreak settings

When topical treatment fails

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🏠 3. Treat All Household Contacts

Even if they have no symptoms.
Give permethrin to everyone at the same time to prevent reinfection.

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🧼 4. Environmental Measures

Wash clothes, bed sheets, and towels in hot water and dry in sun.

Items that cannot be washed → seal in a plastic bag for 72 hours.

Vacuum sofa, carpets, mattresses.

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🤕 5. Relief of Itching

Oral antihistamines (Cetirizine, Chlorpheniramine) for itching.

Calamine lotion or mild topical corticosteroids for eczema/dermatitis.

Warn parents: Itching can continue for 2–4 weeks even after successful treatment.

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🚨 6. When to Refer

If child has:

Crusted scabies

Extensive secondary bacterial infection

Treatment failure after 2 cycles

Age

26/11/2025

Here is a concise, practical, pediatric-focused management guide for Oral Candidiasis (Oral Thrush) in children:

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Management of Oral Candidiasis in Children

1. Diagnosis (clinical)

Typical findings:

White, curd-like plaques on tongue, buccal mucosa, palate

Scrapes off leaving erythematous surface

May have poor feeding, irritability
No labs needed unless recurrent or severe.

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2. First-Line Treatment

A. Infants & Young Children

Topical therapy is preferred.

🔹 Nystatin Oral Suspension 100,000 units/mL

Dose: 1 mL QID

Apply ½ mL to each cheek using a dropper

Continue 7–14 days

Continue at least 48 hours after symptoms resolve

Make sure medicine stays in mouth before swallowing

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3. Alternatives (if no response)

🔹 Clotrimazole Oral Troches (older children ≥3–4 yrs)

1 troche (10 mg) dissolved in mouth 5× daily for 7–14 days

🔹 Fluconazole (oral) — for:

Moderate–severe cases

Failure of topical therapy

Immunocompromised child

Dose:

6 mg/kg PO on day 1, then 3 mg/kg once daily for 7–14 days

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4. Adjunct Measures

Feeding-related:

Boil/sterilize feeding bottles & pacifiers daily

Replace old pacifiers/teats

If breastfeeding: treat maternal ni***es with topical antifungal (clotrimazole/miconazole)

Oral hygiene:

Wipe infant gums and tongue with clean damp gauze after feeds

Avoid unnecessary antibiotics, inhaled steroids without rinsing

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5. When to Investigate

Check underlying issues if:

Recurrent thrush

Not responding to treatment

Severe disease

Failure to thrive

Consider:

Diabetes mellitus

Immunodeficiency (HIV, primary immunodeficiency)

Recent or prolonged antibiotic/steroid use

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6. Follow-Up

Review in 3–5 days if severe or poor intake

Most cases resolve within 1–2 weeks