Pediatric Appendicitis Nonoperative Management Note

Date/Time: [Date and time of documentation]

Location: [ED / Inpatient / Observation unit]

Author/Service: [Author name and credentials / Service role]

Reason for Note: Decision and plan note for nonoperative (antibiotic-first) management of pediatric acute appendicitis

Clinical Summary

[Brief decision-relevant clinical summary] (3-5 sentences. Reference existing H&P if present to avoid duplication. Include: symptom onset and duration in hours; current symptoms including pain location, fever, vomiting; key exam findings distinguishing uncomplicated vs complicated disease such as localized RLQ tenderness vs diffuse peritonitis/guarding; key labs such as WBC; imaging modality and critical findings. Use source attribution language such as "On exam...", "Per labs...", "Per imaging...". Do not infer findings not explicitly reported in the record.)

Diagnosis and Classification

Working diagnosis: Acute appendicitis

Classification: [Uncomplicated (non-perforated) / Complicated (perforation, abscess, or phlegmon) / Uncertain - pending additional information] (If uncertain, state what information is pending and note that eligibility for nonoperative management cannot yet be confirmed.)

Eligibility for Nonoperative Management

(For each domain, indicate status and provide supporting details. If a required element is unknown, state "Unknown - clarification requested" and document plan to resolve. Do not infer imaging findings not explicitly stated in radiology report.)

• Age and symptom duration within institutional thresholds — [Met / Not met / Pending]: [Age] years; symptom duration [X] hours
• WBC and inflammatory markers within acceptable range — [Met / Not met / Pending]: WBC [value], [CRP if available]
• Imaging confirms uncomplicated appendicitis — [Met / Not met / Pending]: [Imaging modality and timestamp]; [Key findings]; Perforation: [Absent / Present / Not stated]; Abscess/phlegmon: [Absent / Present / Not stated]; Appendicolith: [Absent / Present / Not stated] (If any element not stated, document that clarification was requested from radiology.)
• Clinical exam suitable for NOM — [Met / Not met / Pending]: [Localized tenderness without diffuse peritonitis/guarding]; hemodynamically stable; no sepsis
• No excluding conditions — [Met / Not met / Pending]: Immunocompromised: [No / Yes - specify]; Pregnancy test: [Negative / Not indicated (pre-menarchal) / Pending - must result before final disposition]; Communication/monitoring barriers: [None / Specify]
• Social/logistical suitability — [Met / Not met / Pending]: [Reliable caregiver identified]; [Transportation available]; [Able to return promptly]; [Phone access confirmed]
• Overall eligibility: [Eligible / Not eligible / Pending determination] (If pending or not eligible, specify which criteria are not met and plan to re-evaluate.)

Shared Decision-Making

Participants: [Parent/guardian name and relationship]; patient [participated and assented / present but assent not developmentally appropriate / not present - reason]; interpreter: [Not needed / Used - language]. Options discussed: Antibiotic-first (nonoperative) management vs appendectomy. Risks and benefits reviewed: For NOM: chance of initial success, risk of in-admission failure requiring surgery, recurrence risk requiring later appendectomy, need for close follow-up, antibiotic adverse effects. For surgery: operative/anesthesia risks, likelihood of definitive cure. Failure criteria and crossover plan explained. Family values/priorities: [Brief statement or quote reflecting family's stated preferences]. Decision: [Nonoperative antibiotic-first management / Immediate appendectomy] at [time]. Decision aid provided: [Yes / No]. Questions answered: [Yes]. (If family declines NOM, document that it was offered, reason surgery was chosen, and proceed with operative consent documentation.)

Assessment

Primary problem: Uncomplicated acute appendicitis, [eligible for nonoperative management per pathway criteria / eligibility pending - specify]

Secondary problems: [Dehydration / Pain / Nausea / Antibiotic allergy considerations / None] (List only those relevant to plan.)

Plan

Disposition: [Admit to Pediatric Surgery / Admit with hospitalist co-management / Observation unit / Discharge after observation period]; anticipated duration [X hours/days]

Antibiotics:

• IV regimen: [Drug, dose, frequency] — Start time: [Timestamp]
• Transition criteria to oral: [Afebrile, tolerating PO, clinical improvement, other]
• Oral regimen: [Drug, dose, frequency]
• Total duration (IV + PO): [X] days; Target stop date: [Date]
• Pathway deviations: [None / Specify substitution and rationale]

Supportive Care:

• Diet: [NPO / Clear liquids / Advance as tolerated]; advancement criteria: [Specify]
• IV fluids: [Type and rate, or "Not indicated"]
• Pain management: [Regimen]
• Nausea management: [Antiemetic regimen]

Monitoring:

• Vital signs: [Frequency]
• Serial abdominal exams: [Service/clinician] every [frequency]
• Pain score tracking: [Tool and frequency]
• Repeat labs: [Timing, or "Not planned"]

Contingency: If clinical worsening or failure criteria met: notify surgery attending, make NPO, initiate pre-operative preparation, obtain repeat labs/imaging if indicated.

Discharge Plan: (Include only when discharge criteria are met; otherwise state "Patient requires continued observation/admission because [reason]" and omit remaining items.)

• Criteria met: Afebrile [X] hours, pain controlled on oral medications, tolerating oral intake, first oral antibiotic dose tolerated, caregiver education completed, follow-up scheduled
• Prescriptions: [Drug], [dose], [frequency] for [duration]
• Follow-up: [Surgery clinic / PCP / Phone] on [date/time or timeframe] with [provider/service]
• Education completed: [Topics covered]; teach-back confirmed

Failure Criteria

• Worsening or spreading abdominal tenderness; development of diffuse peritonitis or new guarding
• Persistent or rising fever; new or worsening tachycardia
• Increasing pain despite treatment
• Inability to tolerate oral intake or medications
• Clinical deterioration or signs of sepsis
• Family or surgeon elects surgery based on preferences or clinical judgment

Action steps if any criterion met: Notify surgery attending; make NPO; initiate pre-operative preparation; obtain repeat labs/imaging if indicated; document discussion with family and update consent.

Return Precautions

• Increasing or more diffuse abdominal pain
• Fever or rigors
• Persistent vomiting or inability to keep liquids/medications down
• Lethargy, worsening appearance, or recurrence of pain after initial improvement

Instructions: [Return to ED immediately / Call pediatric surgery at (phone number)] for warning signs above. Caregiver education completed; teach-back confirmed understanding of warning signs and how to seek care.

Follow-Up

Appointment: [Surgery clinic / PCP / Phone check] on [date/time or timeframe] to assess symptom resolution, antibiotic tolerance, and readiness for return to usual activities. Communications: [ED team / Hospitalist / Attending surgeon] notified with plan summary. Pending items: [List any pending results or tasks, or "None"]