Subjective
Date of visit
Reason for visit (difficulty retracting foreskin, pain, hygiene concerns)
History of present illness:
Age of onset of phimosis (congenital or acquired)
Tightness of the foreskin (degree of difficulty retracting)
Pain during erection or retraction (location, severity)
Inability to clean under the foreskin (smegma buildup)
Urinary symptoms (dribbling, straining)
Past medical history (relevant conditions, previous surgeries)
Sexual history (if applicable – for adolescents and adults)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of infection)
Genital exam:
Appearance of the penis and foreskin (degree of phimosis)
Ability to retract the foreskin (complete, partial, or inability to retract)
Signs of inflammation or infection (redness, swelling, discharge)
Meatal stenosis (narrowing of the urinary opening) – if present
Assessment
Phimosis (confirmed based on physical exam findings)
Severity of phimosis (tightness, ability for partial or no retraction)
Potential complications (balanitis – inflammation of the glans, paraphimosis – foreskin trapped behind glans)
Consider differential diagnoses (balanitis xerotica obliterans – chronic inflammatory condition)
Plan
Treatment options (depending on severity, age, and patient preference):
Conservative management (steroid creams to improve elasticity of foreskin) – for mild cases
Circumcision (surgical removal of foreskin) – definitive treatment, especially for moderate or severe phimosis or recurrent infections
Analgesics (pain relievers) for discomfort
Education
Explain the diagnosis, treatment options, and potential risks and benefits of each
Importance of maintaining good genital hygiene (washing under the foreskin if possible)
Discuss safe practices for retraction (avoid forceful attempts)
Follow-up
Schedule for next appointment:
Monitor response to treatment (improvement in retraction, symptoms)
Consider referral to a urologist for circumcision (if indicated)
Note: This template is a guide and may need to be modified based on the individual patient’s age, severity of phimosis, and presence of complications.
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 phimosis.