[age]-year-old [sex] presented to the ED with [duration] of fever and associated [symptoms: cough, nasal congestion, rhinorrhea, decreased appetite, irritability]. Parent present at bedside reports patient has been tolerating PO without difficulties, with [no / mild] decrease in appetite and normal urine output. Denies vomiting, diarrhea, rash, or respiratory distress. Immunizations are up to date.
On evaluation, patient appeared well hydrated, interactive, and appropriate for age, with normal capillary refill and no increased work of breathing. Oropharynx clear, tympanic membranes without bulging or erythema, lungs clear to auscultation, and abdomen soft, non-tender, and non-distended.
Differential includes viral upper respiratory infection, early otitis media, influenza, RSV, COVID-19, and early pneumonia, though there were no focal findings to strongly suggest a bacterial source. Findings today are most consistent with a viral process. [COVID, influenza, and RSV tests were negative / pending / positive for ___ / not obtained.]
Patient remained comfortable and interactive throughout the ED visit with stable vital signs and reassuring physical findings. Findings reviewed with the parent at bedside, and supportive care discussed, including weight-based acetaminophen or ibuprofen for fever and encouraging fluids as tolerated. Parent verbalized understanding and was comfortable with the plan for discharge and outpatient follow-up.
Strict return precautions discussed, including persistent fever, respiratory distress, poor oral intake, vomiting, decreased urine output, new rash, or any new or concerning symptoms. Follow-up with pediatrician advised within 48–72 hours or sooner if symptoms worsen.

[age]-year-old [sex] presented to the ED with [duration] of sore throat associated with [symptoms: fever, decreased appetite, odynophagia, mild cough / no cough, nasal congestion]. Parent present at bedside reports patient has been tolerating PO intake [well / poorly] and maintaining normal urine output. Denies vomiting, drooling, neck stiffness, or respiratory distress. Immunizations are up to date.
On exam, patient appeared well hydrated, interactive, and nontoxic. Oropharyngeal exam notable for [tonsillar erythema / exudates / palatal petechiae / none], uvula midline, and no evidence of peritonsillar swelling or trismus. Cervical nodes [tender / non-tender, enlarged / not enlarged]. Lungs clear to auscultation and no meningeal signs or rash observed.
Differential includes streptococcal pharyngitis, viral pharyngitis, early tonsillitis, and mononucleosis, with low concern for peritonsillar abscess, epiglottitis, or retropharyngeal infection given the reassuring airway exam and overall well appearance. Findings today are most consistent with [streptococcal / viral] pharyngitis. [Rapid strep test positive / negative / pending; throat culture sent / not obtained.] [COVID, influenza, and RSV tests negative / positive for ___ / not obtained.]
For confirmed or suspected streptococcal infection, prescribed [amoxicillin / cephalexin / azithromycin] — weight-based dosing — with instructions to complete the full course. Supportive care discussed, including acetaminophen or ibuprofen for fever or throat pain, maintaining hydration, and soft foods as tolerated.
Patient remained comfortable and interactive throughout the ED visit with stable vital signs and reassuring physical findings. Findings reviewed with the parent at bedside, who verbalized understanding and was comfortable with the plan for discharge and outpatient follow-up.
Strict return precautions discussed, including persistent fever, worsening throat pain, drooling, difficulty swallowing or breathing, neck swelling, or any new or concerning symptoms. Follow-up with pediatrician advised within 48–72 hours or sooner if symptoms worsen.

[age]-year-old [sex] presented to the ED with [duration] of ear pain associated with [symptoms: fever, nasal congestion, cough, irritability, decreased appetite]. Parent present at bedside reports patient has been tolerating PO intake [well / poorly] with normal urinary output. Denies vomiting, drainage from the ear, rash, or respiratory distress. Immunizations are up to date.
On exam, patient appeared well hydrated and interactive for age. Right / left tympanic membrane noted to be [erythematous / bulging / dull / effusion present / normal]; no mastoid tenderness, auricular swelling, or drainage. Contralateral ear within normal limits. Lungs clear to auscultation, and oropharynx without erythema or exudate. Neck supple with full range of motion and no lymphadenopathy. Abdomen soft and non-tender.
Differential includes acute otitis media, otitis externa, eustachian tube dysfunction, and viral upper respiratory infection. Findings today are most consistent with [acute otitis media / serous otitis / viral URI with referred ear pain]. [COVID, influenza, and RSV tests negative / positive for ___ / not obtained.]
If bacterial:
 Antibiotic therapy initiated with [amoxicillin / cefdinir / azithromycin], weight-based, and first dose given in the ED. Supportive care discussed with parent, including acetaminophen or ibuprofen for pain or fever, and maintaining hydration. If symptoms fail to improve or worsen despite treatment, advised prompt re-evaluation.
If non-bacterial / watchful waiting:
 Findings reviewed with parent at bedside. Presentation may represent early or serous otitis rather than acute bacterial infection; advised supportive care with acetaminophen or ibuprofen as needed and close follow-up if symptoms persist or worsen.
Patient remained comfortable and interactive throughout the ED visit with stable vital signs and reassuring physical findings. Findings and plan reviewed with parent at bedside, who verbalized understanding and was comfortable with discharge and outpatient follow-up.
Strict return precautions discussed, including persistent fever, worsening ear pain, drainage from the ear, vomiting, lethargy, poor oral intake, new rash, neck stiffness, or any new or concerning symptoms. Follow-up with pediatrician advised within 48–72 hours or sooner if symptoms worsen.

Patient presented with [cough / fever / shortness of breath / malaise] for [duration] prior to arrival. Parent present at bedside reports [persistent cough / decreased appetite / mild fatigue / increased work of breathing] with [no vomiting / no lethargy / no rash]. On exam, patient was alert, interactive, and behaving appropriately for age. Lungs revealed [focal crackles / diminished breath sounds / rhonchi / mild wheezing], with [no retractions / no nasal flaring / normal oxygen saturation]. Findings otherwise reassuring, with no signs of respiratory distress or dehydration.
Differential includes viral pneumonia, bacterial pneumonia, bronchiolitis, asthma or reactive airway exacerbation, and upper respiratory infection. Findings today are most consistent with [bacterial / viral] pneumonia based on clinical picture and [chest x-ray results / auscultatory findings].
Findings and imaging were consistent with [bacterial / viral] pneumonia. Patient was [prescribed / given] [amoxicillin / azithromycin / cefdinir], weight-based, for outpatient treatment. Supportive care discussed with parent at bedside, including acetaminophen or ibuprofen for fever control and encouraging fluids as tolerated. [Continued with prescribed albuterol as needed.] Parent verbalized understanding and was comfortable with the plan for discharge and follow-up.
Return precautions discussed, including but not limited to: worsening or persistent fever, increased work of breathing, chest pain, vomiting, lethargy, poor oral intake, cyanosis, or any new or concerning symptoms. Advised follow-up with pediatrician within 48–72 hours for reassessment or sooner if symptoms worsen.

Patient signed out to [Dr. _____] at [time] with pending [labs / imaging / re-evaluation]. Clinical course and current status reviewed in detail. Disposition options discussed and plan of care conveyed to the receiving provider, who will follow pending results and determine final disposition. Patient remained stable at time of sign-out.`

Patient received in sign-out from [Dr. _____] at [time] with pending [results / re-evaluation / consults]. Prior ED course, findings, and disposition considerations reviewed. Assuming ongoing care and final disposition.`

MDM — Pediatric Head Trauma (No CT, No Observation)

PECARN CALCULATIONS:
Age group: [<2 years / ≥2 years]
Mechanism of injury: [describe]
PECARN ciTBI estimated risk:
    <2 years: <0.02 %
    ≥2 years: <0.05 %
All predictors negative:
    - Normal mental status, GCS 15
    - No loss of consciousness (≥2 y: any; <2 y: ≥5 s)
    - No palpable or basilar skull fracture
    - No non-frontal scalp hematoma (<2 y)
    - No vomiting, severe headache, or severe mechanism

---

Patient presented after minor head trauma with no loss of consciousness, vomiting, or abnormal behavior. On examination, child appeared well, alert, and interactive for age with normal tone, strength, and coordination. Pupils equal and reactive; no scalp hematoma or tenderness; no step-off or signs of basilar skull fracture. Vitals stable and age-appropriate. No focal neurologic deficits.

Based on the PECARN decision rule, patient meets very-low-risk criteria for clinically important traumatic brain injury (estimated risk <0.05%). Given the absence of concerning features and a reassuring neurologic exam, no head CT or prolonged observation is indicated. Discussed the extremely low probability of intracranial injury and risks associated with radiation exposure with the parent, who agreed with home observation. All questions answered and expectations reviewed.

Patient remained well-appearing and interactive during ED course. Discharged home with strict return precautions for persistent vomiting, worsening headache, confusion, seizure, focal deficits, lethargy, or poor oral intake. Advised follow-up with pediatrician within 48 hours or sooner if concerns arise.

MDM — Pediatric Head Trauma (Observation without CT)

PECARN CALCULATIONS:
Age group: [<2 years / ≥2 years]  
Mechanism of injury: [describe]  
PECARN ciTBI estimated risk:  
 < 2 years ≈ 0.9 %  ≥ 2 years ≈ 0.8 %  
Low-risk group with intermediate factor(s): [list specific factor(s)]  
 - Normal mental status / GCS 15  
 - No palpable or basilar skull fracture  
 - No signs of focal neurologic deficit  
 - May have isolated vomiting / brief LOC / mild headache / frontal hematoma  
 - Mechanism not severe  

---

Patient presented after minor head trauma with [brief loss of consciousness / single vomit / mild headache] and otherwise normal behavior per caregiver. Exam revealed a well-appearing, interactive child with normal pupils, tone, strength, and coordination. No skull tenderness or step-off appreciated; tympanic membranes clear; no basilar signs. Vitals stable and appropriate for age.

Using the PECARN rule, patient falls within the low-risk “observation” zone (< 1 % risk for ciTBI). Given the absence of high-risk findings and reassuring exam, CT was deferred in favor of ED observation with serial neurologic assessments. Family counseled regarding small residual risk of intracranial injury versus radiation exposure from CT, and agreed with observation.

Patient observed in the ED for [__ hours] with stable vitals, normal serial neuro exams, and no further vomiting or changes in behavior. Findings remained reassuring. Discussed warning signs and need for prompt return if headache, vomiting, confusion, seizure, lethargy, or any new neurologic deficits develop. Discharged home in stable condition with follow-up arranged with pediatrician within 24–48 hours.

MDM — Pediatric Head Trauma (CT Recommended)

PECARN CALCULATIONS:
Age group: [<2 years / ≥2 years]  
Mechanism of injury: [describe]  
PECARN ciTBI estimated risk:  
 < 2 years ≈ 4.4 %  ≥ 2 years ≈ 4.3 %  
High-risk feature(s) present: [list specific findings]  
 - Abnormal mental status or GCS < 15 at 2 hours  
 - Palpable skull fracture (< 2 y) / Signs of basilar skull fracture (≥ 2 y)  
 - Severe mechanism (fall > 3 ft < 2 y / > 5 ft ≥ 2 y; pedestrian / bicyclist struck; high-impact object)  
 - Repeated vomiting / severe headache  
 - Any focal neuro deficit or seizure  

---

Patient presented after [mechanism] with [concerning symptom: vomiting, altered mental status, skull defect, or severe headache]. On arrival, GCS [15 / less if applicable]; pupils equal and reactive; no significant external bleeding. Exam revealed [palpable frontal step-off / battle sign / periorbital ecchymosis / hematoma description]. Neurologic exam otherwise intact. Vitals stable.

By PECARN criteria, presence of [high-risk finding] places patient in the imaging pathway with ≈4 % risk for ciTBI. Discussed the evidence-based recommendation for head CT to exclude intracranial injury and reviewed the benefits and radiation risks with the parent. Consent obtained for imaging after shared decision-making.

Patient remained hemodynamically stable and interactive while awaiting CT. Imaging [negative / demonstrated ___]. If negative, findings consistent with minor head injury without intracranial pathology; family counseled on home observation and return precautions. If positive, neurosurgery and pediatrics consulted for management and admission as indicated. All results and follow-up instructions reviewed with caregiver who verbalized understanding.

MDM — Neonatal Hyperbilirubinemia (Below Phototherapy Threshold)

BILIRUBIN CALCULATIONS / RISK FACTORS:
Age at sampling: [__ hours] Gestational age: [__ weeks + __ days] Birth weight: [__ g]  
Feeding / weight loss: [breast / formula ; __ % loss]  
AAP 2022 Risk Factors: [none / GA < 38 w / isoimmune hemolysis / G6PD / sepsis / albumin < 3.0 / bruising or cephalohematoma]  
Measurements: TSB [__ mg/dL] at [__ h] Phototherapy threshold [__ mg/dL] Δ to threshold = [__ mg/dL] (below)  
Exchange threshold [__ mg/dL] Risk curve / percentile [__]

---

Infant evaluated for neonatal jaundice at [__ hours] of life. Well appearing, alert, and feeding [adequately / improving] with stable vitals and no evidence of lethargy, poor tone, or dehydration. No scleral icterus beyond mild facial/chest jaundice. TSB of [__ mg/dL] is below the AAP phototherapy threshold of [__ mg/dL] for gestational age and risk profile, placing infant in the low-risk zone for clinically significant hyperbilirubinemia.

Findings consistent with physiologic jaundice. Discussed expected bilirubin course and importance of frequent feeds to optimize enteric clearance. Family educated on return precautions for poor feeding, lethargy, dark urine, acholic stools, or worsening jaundice to the lower extremities. Plan for repeat bilirubin check within 24–48 hours and close pediatric follow-up. Caregivers verbalized understanding and comfort with home observation.

MDM — Neonatal Hyperbilirubinemia (Phototherapy Initiated)

BILIRUBIN CALCULATIONS / RISK FACTORS:
Age at sampling: [__ hours] Gestational age: [__ weeks + __ days] Birth weight: [__ g]  
AAP 2022 Risk Factors: [GA < 38 w / isoimmune hemolysis / G6PD / sepsis / albumin < 3.0 / other]  
Measurements: TSB [__ mg/dL] at [__ h] Phototherapy threshold [__ mg/dL] Δ to threshold = [__ mg/dL] (at/above)  
Exchange threshold [__ mg/dL] Rate of rise (if known) [__ mg/dL/hr]

---

Infant presented with progressive jaundice; on exam alert and interactive with normal tone and suck. No signs of acute bilirubin encephalopathy. Serum bilirubin above AAP phototherapy threshold for age and risk factors. No dehydration or clinical signs of infection.

Initiated intensive phototherapy using LED blue lights with maximized body surface exposure and eye protection in place. Encouraged frequent feeds to enhance bilirubin elimination and monitored intake/output. No signs of hemolysis or cephalohematoma requiring additional intervention. Family counseled on treatment course, expected timeline for decline in TSB, and need for serial levels to confirm response.

Patient tolerated therapy well with stable vitals and improving jaundice trend. Plan for TSB recheck in 4–6 hours to confirm decrease, continue phototherapy until TSB is > 2 mg/dL below threshold and trending down. If criteria met, phototherapy to be stopped with rebound TSB draw 6–12 hours later as indicated. Parents informed of follow-up requirements and return precautions.

MDM — Neonatal Hyperbilirubinemia (Escalation / Exchange Threshold)

BILIRUBIN CALCULATIONS / RISK FACTORS:
Age at sampling: [__ hours] Gestational age: [__ weeks + __ days] Birth weight: [__ g]  
Risk Factors: [isoimmune hemolysis / G6PD / sepsis / albumin < 3.0 / GA < 38 w / other]  
Measurements: TSB [__ mg/dL] at [__ h] Phototherapy threshold [__ mg/dL] Exchange threshold [__ mg/dL]  
Δ to exchange = [__ mg/dL] (≥ 0 = at/above) Rate of rise [__ mg/dL/hr]

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Infant with known hyperbilirubinemia on intensive phototherapy demonstrating TSB at or above the AAP exchange threshold. Examination shows alertness with slightly diminished tone but no overt signs of acute bilirubin encephalopathy. Vitals stable, feeding adequate. IV access established and volume status addressed.

Given TSB [__ mg/dL] at [__ hours] of life and Δ to exchange of [__ mg/dL], consulted Neonatology / NICU for escalation of care and potential exchange transfusion. Additional labs obtained including blood type, DAT/Coombs, CBC/retic, bilirubin fractionation, albumin, and G6PD level. If isoimmune hemolysis present, considered IVIG per AAP protocol. Supportive care continued with maximal phototherapy and temperature monitoring.

Discussed clinical status and risk of bilirubin neurotoxicity with caregivers; family understood need for NICU-level management and possible exchange procedure. Patient remained hemodynamically stable during transfer preparations.