What are the soap and admitting orders for a 2-year-old female patient weighing 10kg with a 1-month history of productive cough, diagnosed with community-acquired pneumonia (PCAP C) and bronchopneumonia?

SOAP and Admitting Orders for 2-Year-Old with Community-Acquired Pneumonia

SOAP Note

Subjective

• 2-year-old female, 10 kg
• Chief Complaint: 1-month productive cough
• History of Present Illness: Prolonged productive cough for 1 month, now with radiographic confirmation of bronchopneumonia 1
• Review of Systems: Document presence/absence of fever, respiratory distress, feeding difficulties, lethargy, and any recent sick contacts 1

Objective

• Weight: 10 kg
• Vital Signs Required:
  • Temperature (fever >38.5°C suggests bacterial etiology) 1
  • Respiratory rate (>50/min in this age group indicates severity) 1
  • Oxygen saturation (SpO2 <92% requires hospitalization) 1
  • Heart rate (assess for sustained tachycardia) 1
  • Blood pressure 1
• Physical Examination:
  • Assess for chest retractions, nasal flaring, grunting 1
  • Auscultate for crackles, decreased breath sounds, wheezing (wheeze suggests viral etiology) 1
  • Evaluate work of breathing and general appearance 1
• Imaging: CXR showing bronchopneumonia (already obtained) 1

Assessment

Primary Diagnosis: Community-acquired pneumonia (bacterial, presumed) with bronchopneumonia pattern in a 2-year-old 1

Severity Assessment: This child requires hospitalization given the 1-month duration suggesting treatment failure or complicated course, warranting inpatient management 1

Plan

Proceed to admitting orders below.

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Admitting Orders

1. Admission Status

• Admit to: Pediatric ward with continuous pulse oximetry monitoring 1
• Admit to ICU if: SpO2 <92% on FiO2 ≥0.50, impending respiratory failure, altered mental status, or need for positive pressure ventilation 1

2. Diagnosis

• Community-acquired pneumonia (bacterial, presumed) 1

3. Condition

• Stable/guarded (depending on clinical presentation)

4. Vital Signs

• Every 4 hours minimum including continuous pulse oximetry 1
• Monitor for: temperature, heart rate, respiratory rate, blood pressure, oxygen saturation 1

5. Activity

• Bed rest with minimal handling to reduce oxygen requirements 1

6. Diet

• Age-appropriate diet as tolerated 1
• NPO if: severe respiratory distress or vomiting 1
• Avoid nasogastric tubes in severely ill children as they may compromise breathing; if absolutely necessary, use smallest tube in smallest nostril 1

7. IV Fluids

• Maintenance fluids at 80% of basal requirements 1, 2
• For 10 kg child: approximately 800 mL/24 hours (33 mL/hour) of D5 0.45% NaCl
• Monitor serum electrolytes 1, 2

8. Oxygen Therapy

• Supplemental oxygen to maintain SpO2 >92% via nasal cannula, head box, or face mask 1, 2
• Titrate FiO2 as needed 1

9. Medications

Antibiotic Therapy (Primary Treatment)

For this 2-year-old (10 kg) with presumed bacterial pneumonia requiring hospitalization:

Ampicillin 250 mg IV every 6 hours (100 mg/kg/day divided q6h) 1

• Alternative: Ceftriaxone 500 mg IV once daily (50 mg/kg/day, max 2g) 1
• Alternative: Cefotaxime 500 mg IV every 8 hours (150 mg/kg/day divided q8h) 1

Rationale: This child is fully immunized (assumed standard vaccination schedule), making ampicillin or penicillin G appropriate first-line therapy for hospitalized patients 1. The prolonged 1-month course raises concern for possible atypical pathogen or treatment failure.

Add Azithromycin 100 mg IV/PO once daily (10 mg/kg on day 1, then 5 mg/kg days 2-5) if atypical pneumonia cannot be excluded 1, 3

Add Vancomycin 150 mg IV every 6 hours (60 mg/kg/day divided q6h) OR Clindamycin 100 mg IV every 6 hours (40 mg/kg/day divided q6-8h) if CA-MRSA suspected (necrotizing pneumonia, empyema, severe illness) 1

Supportive Medications

• Acetaminophen 150 mg PO/PR every 4-6 hours PRN fever >38.5°C or discomfort (15 mg/kg/dose) 1, 2
• Ibuprofen 100 mg PO every 6-8 hours PRN fever or pain (10 mg/kg/dose) 1

10. Laboratory Studies

• Blood cultures x2 (from separate sites) BEFORE starting antibiotics 1
• Complete blood count with differential 2
• Basic metabolic panel (baseline and to monitor electrolytes with IV fluids) 1
• Save acute serum sample for possible convalescent titers if diagnosis unclear 1
• Nasopharyngeal aspirate for viral testing (RSV, influenza, other respiratory viruses) given age <18 months 1
• Consider: Blood gas if severe respiratory distress 1

11. Nursing Orders

• Skilled pediatric nursing care 1
• Pulse oximetry continuous 1
• Strict intake and output 1
• Notify physician if:
  • SpO2 <92% on current oxygen therapy 1
  • Respiratory rate >70/min 1
  • Temperature >39°C or <36°C 1
  • Increased work of breathing, grunting, or apnea 1
  • Altered mental status 1
  • Inadequate oral intake 1

12. Respiratory Care

• NO chest physiotherapy (not beneficial and should not be performed) 1, 2
• Encourage coughing and deep breathing when comfortable 1

13. Monitoring and Follow-up

• Reassess clinical status at 48-72 hours for expected improvement 1, 4
• If no improvement or deterioration at 48-72 hours:
  • Repeat blood cultures 1
  • Consider chest ultrasound or repeat CXR to evaluate for complications (parapneumonic effusion, empyema, lung abscess) 1
  • Broaden antibiotic coverage 1
  • Consider alternative diagnoses (immunodeficiency, foreign body, tuberculosis) 1

14. Transition to Oral Therapy

• Switch from IV to oral antibiotics when:
  • Clear clinical improvement (decreased fever, improved respiratory status) 1
  • Tolerating oral intake 1
  • Typically after 24-48 hours of clinical stability 1
• Oral regimen: Amoxicillin 450 mg PO twice daily (90 mg/kg/day in 2 doses) to complete 7-10 day total course 1

15. Discharge Planning

• Discharge criteria:
  • Afebrile for 24 hours 4
  • SpO2 >92% on room air 1
  • Tolerating oral intake and medications 1
  • Reliable follow-up available 1
• Follow-up: Outpatient visit in 48-72 hours post-discharge 1, 2
• Repeat CXR only if: Lobar collapse, round pneumonia appearance, or persistent symptoms at follow-up 1, 2

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Key Clinical Pitfalls

The 1-month duration of symptoms is concerning and suggests either:

• Initial viral infection with secondary bacterial superinfection 4
• Inadequate outpatient antibiotic therapy (wrong drug, wrong dose, or resistant organism) 1
• Complicated pneumonia (empyema, abscess) 1
• Alternative diagnosis (foreign body aspiration, tuberculosis, immunodeficiency) 1

This prolonged course mandates hospitalization even if current vital signs are stable, as it indicates treatment failure requiring IV antibiotics and close monitoring 1.