What are the admitting orders and diagnosis for a patient with suspected acute respiratory infection?

Admitting Orders and Diagnosis for Suspected Acute Respiratory Infection

Admitting Diagnosis

Acute Respiratory Infection (specify: Community-Acquired Pneumonia, Bronchiolitis, or Viral Upper Respiratory Infection based on clinical presentation and age)

The diagnosis should be established primarily through clinical assessment including travel history, exposure history, symptom onset and progression, and physical examination findings rather than extensive laboratory workup 1.

Admission Location and Isolation Precautions

Admit to isolation unit with appropriate infection control measures 1:

• Place patient in negative pressure room if available, particularly if severe acute respiratory syndrome or highly transmissible pathogen suspected 1
• Implement droplet and contact precautions at minimum 1
• Restrict visitors to next of kin/legal guardian only 1
• Maintain detailed log of all staff contact with patient 1
• Ensure all staff use gowns, gloves, goggles/visors, and appropriate respirators 1
• Hand decontamination with alcohol-based rubs is mandatory before and after patient contact 2

Initial Diagnostic Workup

Imaging Studies

• Chest X-ray (portable if possible to minimize transport) 1
• Avoid routine chest radiography in mild cases; reserve for severe respiratory distress or suspected complications like pneumothorax 2

Laboratory Testing

Blood Work 1:

• Complete blood count with differential
• Basic metabolic panel (sodium, potassium, chloride, bicarbonate, BUN, creatinine)
• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase)
• Lactate dehydrogenase
• Creatinine kinase
• C-reactive protein
• Blood cultures if bacterial infection suspected

Microbiological Specimens (observe strict infection control with double-bagging and biohazard labeling) 1:

• Expectorated sputum if available (do NOT obtain nasopharyngeal aspirate as this generates aerosols) 1
• EDTA blood (20 ml for PCR if viral testing indicated)
• Acute serology (20 ml clotted blood)
• Urine (20-30 ml)
• Stool sample
• Viral testing only if it will change management or for epidemiological surveillance 2

Respiratory Assessment

• Pulse oximetry on admission and ongoing monitoring 1
• Arterial blood gas if oxygen saturation <92% on room air 1

Therapeutic Orders

Oxygen Therapy

Administer supplemental oxygen if SpO2 persistently <90% in previously healthy patients 2:

• Use low-flow oxygen delivery systems (≤6 L/min) to minimize aerosol generation 1
• Target 30-40% oxygen supplementation using standard low-flow system with air-entrainer and Ventimask 1
• Avoid high-flow oxygen (>6 L/min) due to increased infection transmission risk 1
• Discontinue oxygen when SpO2 ≥90%, patient feeding well, and minimal respiratory distress present 2
• Patients with hemodynamically significant heart/lung disease or prematurity require closer monitoring during weaning 2

Antimicrobial Therapy

Initiate empiric antibacterial coverage for community-acquired pneumonia 1:

• First-line: IV co-amoxiclav 1.2 g three times daily PLUS erythromycin 500 mg four times daily 1
• Alternative: IV cefuroxime 1.5 g three times daily PLUS clarithromycin 500 mg twice daily 1
• Antibiotics should only be used when bacterial coinfection is specifically indicated, not routinely for viral infections 2

Fluid Management

Assess hydration status and oral intake capability 2:

• IV fluids indicated if patient cannot feed safely due to respiratory distress 2
• Monitor for fluid retention related to antidiuretic hormone production in respiratory infections 2
• Maintain adequate hydration while avoiding fluid overload

Medications to AVOID (Unless Specific Indications)

Do NOT routinely administer 2:

• Bronchodilators (albuterol/salbutamol) - only continue if documented objective clinical response after trial 2
• Corticosteroids - consider moderate-dose prednisolone 30-40 mg/day (or IV equivalent) ONLY in severely ill patients with PaO2 <10 kPa or SpO2 <90% on room air 1
• Ribavirin 2
• Chest physiotherapy 2

Symptomatic Management

• NSAIDs may be used for fever and symptom control; no evidence they worsen viral respiratory infections 3
• Antipyretics as needed for comfort

Respiratory Support Considerations

Aerosol-Generating Procedures

Avoid whenever possible to protect healthcare workers 1:

• If intubation required, use experienced operators only 1
• Perform in negative pressure room with minimum staff present 1
• Plan procedures electively rather than emergently 1
• Avoid CPAP and non-invasive ventilation; consider early intubation with invasive positive pressure ventilation instead 1

Critical Care Planning

• Early consultation with ICU if patient shows signs of impending respiratory failure 1
• Approximately 20% of severe respiratory infection patients may require ICU admission 1
• Patients requiring oxygen therapy need prolonged hospitalization (median 8-12 days) 4

Monitoring Parameters

Daily assessments should include 1:

• Vital signs including temperature, respiratory rate, heart rate, blood pressure
• Oxygen saturation (continuous monitoring not needed once clinical course improves) 2
• Respiratory effort and work of breathing
• Ability to maintain oral intake
• Fever duration (typically 7 days in viral infections) 4
• CRP levels (may remain elevated until discharge) 4

Risk Stratification

Identify high-risk features requiring closer monitoring 1, 2:

• Age <12 weeks (for bronchiolitis) 2
• History of prematurity (<35 weeks gestation) 2
• Underlying cardiopulmonary disease 1, 2
• Diabetes mellitus 1
• Immunodeficiency 2

Common Pitfalls to Avoid

• Do not order routine viral testing unless it changes management or patient receives palivizumab prophylaxis 2
• Do not obtain nasopharyngeal aspirates due to aerosol generation risk 1
• Do not use high-flow oxygen (>6 L/min) unnecessarily 1
• Do not routinely use bronchodilators or corticosteroids without specific indications 2
• Do not underestimate oxygen requirements - patients may have significant hypoxemia without dyspnea 4
• Do not discharge prematurely - oxygen-dependent patients require prolonged hospitalization 4