RequiredBefore you begin, print out all the pages in this workbook.Roth Contractors Corporation was incorporated on December 1, 2019.Required:Part A1Prepare journal entries to record the December transactions shown on page "Transactions Pt. A". General ledger account numbers and descriptions are not needed.2Post the entries to general ledger T-accounts.Part B3Prepare all necessary adjusting entries based on the information shown on the printed "Adj. Entries Pt. B" page. General ledger account numbers and descriptions are not necessary.4Post the entries to general ledger T-accounts and calculate balances.5Prepare an adjusted trial balance at December 31.6Prepare an income statement, statement of changes in equity, and balance sheet. Assume the fiscal year-end is December 31, 2019.7Prepare closing entries and a post-closing trial balance at December 31, 2019. Transactions Pt. A2019DecemberTransactionsAmounta.Issued common stock for cash2,000b.Paid cash for three month's rent: December 2019, January and February 20202,400c.Purchased a used truck on credit (recorded as an account payable)13,000d.Purchased supplies on credit. These are expected to be used during the month (recorded as expense)1,600e.Paid for a one-year truck insurance policy, effective December 12,280f.Billed a customer for work completed to date6,000g.Collected cash for work completed to date4,000h.Paid the following expenses in cash: Advertising700 Interest700 Telephone800 Truck operating600 Wages5,000i.Collected part of the amount billed in f above1,000j.Billed customers for work completed to date7,000k.Signed a contract for work to be performed in January 202090005,000l.Paid the following expenses in cash: Advertising600 Interest600 Truck operating900 Wages2,000m.Collected an advance on work to be done in January (the policy of the coproration is to record such advances as revenue at the the time they are received)2,000n. Received a bill for electricity used during the month (recorded as utilities expense)800 Adj. Entries Pt. B2019DecemberAdjusting EntriesAmounto.One month of the prepaid insurance has expired.$170p.The December portion of the rent paid on December 1 has expired.$900q.Counted supplies and found this amount still on hand (recorded the amount used as an expense)$100r.The amount collected in transaction m is unearned at December 31.$2,000s.Three days of wages for December 29, 30, and 31 are unpaid. These will be paid in January.$2,900t.One month of depreciation needs to be recorded. Estimated useful life of truck in years is:361.11111111113u.Income taxes expense to be paid in the next fiscal year.$100 T-accountsRoth Contractors CorporationCash Accounts PayableRepair RevenueRent ExpenseSupplies ExpenseAccounts ReceivableWages PayableAdvertising ExpenseTelephone ExpenseUnearned Repair RevenuePrepaid InsuranceIncome Taxes PayableDepreciation Exp. - TruckTruck Operating ExpensePrepaid RentCommon StockInsurance ExpenseUtilities ExpenseUnused SuppliesInterest ...

1. RequiredBefore you begin, print out all the pages in this
workbook.Roth Contractors Corporation was incorporated on
December 1, 2019.Required:Part A1Prepare journal entries to
record the December transactions shown on page "Transactions
Pt. A". General ledger account numbers and descriptions are not
needed.2Post the entries to general ledger T-accounts.Part
B3Prepare all necessary adjusting entries based on the
information shown on the printed "Adj. Entries Pt. B" page.
General ledger account numbers and descriptions are not
necessary.4Post the entries to general ledger T-accounts and
calculate balances.5Prepare an adjusted trial balance at
December 31.6Prepare an income statement, statement of
changes in equity, and balance sheet. Assume the fiscal year-
end is December 31, 2019.7Prepare closing entries and a post-
closing trial balance at December 31, 2019.
Transactions Pt. A2019DecemberTransactionsAmounta.Issued
common stock for cash2,000b.Paid cash for three month's rent:
December 2019, January and February 20202,400c.Purchased a
used truck on credit (recorded as an account
payable)13,000d.Purchased supplies on credit. These are
expected to be used during the month (recorded as
expense)1,600e.Paid for a one-year truck insurance policy,
effective December 12,280f.Billed a customer for work
completed to date6,000g.Collected cash for work completed to
date4,000h.Paid the following expenses in cash:
Advertising700 Interest700 Telephone800 Truck operating600
Wages5,000i.Collected part of the amount billed in f
above1,000j.Billed customers for work completed to
date7,000k.Signed a contract for work to be performed in
January 202090005,000l.Paid the following expenses in cash:
Advertising600 Interest600 Truck operating900
Wages2,000m.Collected an advance on work to be done in
January (the policy of the coproration is to record such
advances as revenue at the the time they are received)2,000n.

2. Received a bill for electricity used during the month (recorded
as utilities expense)800
Adj. Entries Pt. B2019DecemberAdjusting EntriesAmounto.One
month of the prepaid insurance has expired.$170p.The
December portion of the rent paid on December 1 has
expired.$900q.Counted supplies and found this amount still on
hand (recorded the amount used as an expense)$100r.The
amount collected in transaction m is unearned at December
31.$2,000s.Three days of wages for December 29, 30, and 31
are unpaid. These will be paid in January.$2,900t.One month of
depreciation needs to be recorded. Estimated useful life of truck
in years is:361.11111111113u.Income taxes expense to be paid
in the next fiscal year.$100
T-accountsRoth Contractors CorporationCash Accounts
PayableRepair RevenueRent ExpenseSupplies ExpenseAccounts
ReceivableWages PayableAdvertising ExpenseTelephone
ExpenseUnearned Repair RevenuePrepaid InsuranceIncome
Taxes PayableDepreciation Exp. - TruckTruck Operating
ExpensePrepaid RentCommon StockInsurance ExpenseUtilities
ExpenseUnused SuppliesInterest ExpenseWages
ExpenseTruckAcc. Dep'n - TruckIncome Taxes Expense
Jnl. EntriesRoth Contractors CorporationGENERAL
JOURNALDec.2019DescriptionFDebitCreditRoth Contractors
CorporationGENERAL
JOURNALDec.2019DescriptionFDebitCreditRoth Contractors
CorporationGENERAL
JOURNALDec.2019DescriptionFDebitCredit
Adj. Trial Bal.Roth Contractors CorporationAdjusted Trial
BalanceAt December 31, 2019Post-closing Trial
BalanceAccounts BalancesClosing EntriesAccount
TitleDebitCredit#DebitCredit#DebitCreditCashAccounts
ReceivablePrepaid InsurancePrepaid RentUnused
SuppliesTruckAccum. Dep'n. - TruckAccounts PayableWages
PayableIncome Taxes PayableUnearned RevenueCommon
StockRetained EarningsIncome SummaryRepair
RevenueAdvertising ExpenseDep'n. Expense - TruckInsurance

3. ExpenseInterest ExpenseRent ExpenseSupplies
ExpenseTelephone ExpenseTruck Operating ExpenseUtilities
ExpenseWages ExpenseIncome Taxes Expense
StatementsRoth Contractors CorporationRoth Contractors
CorporationIncome StatementBalance SheetFor the Month
Ended Dec. 31, 2019At December 31,
2019RevenueAssetsExpensesLiabilitiesRoth Contractors
CorporationStatement of Changes in EquityStockholders'
EquityFor the Month Ended December 31, 2019Common
stockRetained earningsTotal equityOpening balanceEnding
balance
CopyrightCopyright © 2018 David AnnandPublished by David
AnnandBox 308, Rochester AB T0G 1Z0ISBN: 978-0-9953266-
6-8 Library and Archives Canada Cataloguing in
PublicationAnnand, David, 1954–This case is licensed under a
Creative Commons License, Attribution–Non-commercial–Share
Alike 4.0 USA see www.creativecommons.org. This material
may be reproduced for non-commercial purposes and changes
may be used by others provided that credit is given to the
author.To obtain permission for uses beyond those outlined in
the Creative Commons license, such as personalized
assignments for students, please contact David Annand at
[email protected]Latest version available at
https://open.bccampus.ca/find-open-textbooks/Please forward
suggested changes to [email protected]First US EditionJuly 31,
2018
East Tennessee State University
Soap Example 3
Background Information
Patient originally arrived at the emergency department by
ambulance at Bristol Regional Medical Center on April 4th,
2012 after experiencing a fall at Greystone Nursing Facility.
After the fall, her saturation was 86% on five liters.

4. Chief complaint: Patient complained that she had hit her head
and could not breathe. She also complained of back and neck
pain.
Objective: The patient was given Xopenex at 0.63mg and
Pulmicort at 180mcg. Due to her low oxygen saturation and
respiratory failure, she was placed on BIPAP as well. However,
her saturation continued to drop and her arterial blood gas
showed persistent hypoxemia as well as hypercarbia, despite
100% FIO2 on BIPAP, therefore, the decision was made to
intubate at that time.
She was also thought to have respiratory failure with a COPD
exacerbation and congestive heart failure exacerbation.
The patient was later trached on April 13th, 2012 and moved to
Select Specialty Hospital on April 19th, 2012, where she was
weaned off of the ventilator and returned to Greystone Nursing
Facility.
However, on May 3, 2012, she returned to the emergency
department at BRMC as a full code due to cardiac arrest and
respiratory failure. She was intubated, moved to the ICU, and
later trached and then moved on May 11, 2012 to the IMU at
BRMC.
History and Physical
-Co-morbidities:
Co-Morbidity
Definition
Treatment/Management
Hypernatremia
An electrolyte problem defined as a rise in serum sodium

5. concentration above 145 mEq/l (Lukitsch, 2010).
Recognizing the symptoms when present, identifying the
underlying cause, correcting the volume disturbance, and
correcting the hypertonicity (Lukitsch, 2010).
Anemia
A condition in which the hemoglobin is below normal (Nabili,
2012).
Identify the underlying cause, iron supplements, blood
transfusions, or Vitamin B12 injections (Nabili, 2012).
Thrombocytopenia
Any disorder in which there is an abnormally low amount of
platelets (Thrombocytopenia, 2012).
Treatment depends on the cause of the condition. Usually a
transfusion of platelets is required (Thrombocytopenia, 2012).
Congestive Heart Failure (CHF)
A condition in which the heart’s function as a pump is
inadequate to meet the body’s needs (Kulick, 2012).
Lifestyle modification, addressing potentially reversible factors,
medications, heart transplant and mechanical therapies (Kulick,
2012).
Obstructive Sleep Apnea (OSA)
A sleep disorder involving cessation or significant decrease in
airflow in the presence of breathing effort (Downey 2012).
Weight loss, changing sleeping position, avoiding alcohol
before bed, CPAP and BIPAP (Downey, 2012).
Mild Obesity
The state of being well above one’s normal weight (Definition,
2012).
Dietary changes, exercise, counseling/support, and medication
(Definition, 2012).
Hypertension
When a person’s blood pressure is persistently above
140/90mmHg. The cause is often unknown, but it probably is
“the result of increased systemic vascular resistance or an
increased force on ventricular contraction” (Wilkins, Stoller and
Kacmarek, 2009, p.328)

6. Making lifestyle changes (those that would affect blood
pressure and reduce cardiovascular risk) as well as medications,
including diuretics, alpha- and beta-adrenergic blockers,
antihypertensives, calcium channel blockers, ACE inhibitors,
and vasodilators (Riaz, 2012).
Gastroesophageal reflux disease (GERD)
The spontaneous return of gastric contents into the esophagus.
The main symptom is frequent heartburn (Heartburn, 2007).
Medications, lifestyle changes, including eating small, frequent
meals, and stop smoking, and possibly even surgery (Heartburn,
2007).
Chronic Kidney Disease (Stage III)
Occurs when someone suffers from gradual and usually
permanent loss of kidney function over time (Kathuria, 2012).
Dietary changes, medications, stop smoking, lose weight
(Kathuria, 2012).
Chronic Obstructive Pulmonary Disease (COPD)
A chronic, ongoing, progressive disease of the lower respiratory
tract in the lungs (Treatments, 2012).
Quit smoking and control symptoms by using medications such
as bronchodilators, corticosteroids, and oxygen (Treatments,
2012).
Type II Diabetes
A lifelong disease in which there are high levels of sugar in the
blood, because the person’s body cannot move sugar into fat,
liver, and muscle cells to be stored for energy (Eltz and Zieve,
2012).
Medication, diet, and exercise (Eltz and Zieve, 2012
Hypothyroidism
A condition characterized by abnormally low thyroid hormone
production (Mathur, 2012).
Synthetic T4 replacement (Mathur, 2012).
Cardiomyopathy
A disease that weakens and enlarges the heart muscle
(Cardiomyopathy, 2012).
Depending on which type may include, drugs, surgery, and

7. pacemakers (Cardiomyopathy, 2012).
-Home Medications:
Drug Name
Dosage
Indications
Acetaminophen (Tylenol)
650 mg
Used for mild pain.
Carvedilol (Coreg)
6.25mg
Treatment of cardiomyopthy.
Fluticasone (Advair)
50mcg
Used to manage COPD.
Gabapentin (Gralise)
100mg
Used to manage postherpetic neuralgia.
Levothyroxine (Levothroid)
75mcg
Used to manage hypothyroidism.
Metolazone (Zaroxolyn)
1mg
Used to treat hypertension and water retention in CHF.
Theophylline
350mg
Used to manage COPD.
Torsemide (Demadex)
10-20mg
Used to treat edema associated with CHF.
Levemir (Insulin Detemir)
35 units
Used to manage diabetes.
Coumadin (Warfarin)
5mg
Used to treat thromboembolic complications.

8. (PDR, 2012)
-Past Surgical History: 1. Automatic implantable Cardioverter-
defibrillator placement 2. Tubal Ligation 3. Tonsillectomy 4.
Adenoidectomy 5. Cesarean Section 6. Pacemaker placement
-Age: 52
-Gender: Female
-Height: 160.02cm (63in)
-Actual Weight: 102kg (224.4lbs)
-Ideal Body Weight: 45.5 + (2.3 x 63) -60 = 130.4lbs
-Smoking History: 1 pack per day x 25 years= 25 pack years
-Physical Assessment:
-Vitals: (5/11/12): Blood Pressure: 118/90
Pulse: 108
Total Respiratory Rate: 14

9. Temperature: 37C (98.6F)
Saturation: 92% on 100% FIO2
-General: Patient is awake but does not respond to questions.
Pupils are equal, round and reactive to light.
- Neck: No jugular venous distention noted. Has a
tracheostomy intact with ventilatory support.
-Lungs: Bruising on left chest area.
-Cardiac: Tachycardiac at 108bpm.
-Abdomen: Has an umbilical hernia. Her bowel sounds are
decreased. Abdomen is distended. Percutaneous endoscopic
gastrostomy is intact.
-Extremities: She has a left hand small hematoma area. Has a
trace of edema in lower extremities and in thigh areas (+2-+3
pitting edema).

10. -Neurology: Awake but did not mouth any words, just smiled.
-Breath Sounds: Rhonchi and wheezes bilaterally.
-Home Oxygen: Patient uses 3LPM via nasal canula at
Greystone Nursing Facility.
-Social History: No history of alcohol or illicit drug use. Stays
at Greystone Nursing Facility.
-Previous Pulmonary History: Patient has significant history of
COPD.
-Allergies: Patient is allergic to latex. It causes dryness,
itching, and burning).
-Chest Radiograph: Taken on 5/11/12. Showed a cardiac pacer,
right picc line and tracheostomy. There was improvement in
aeration in the right lower lung zone, but there was also
development of patchy pulmonary opacities in the right
perihilar area and extending into the right apex. Opacities in
the left lower lung zone appeared more confluent than
previously. Cardiomegaly demonstrated. Pleural effusion may
have developed. Co-existing CHF not excluded.
Equipment
The patient needs a ventilator for the time being. Along with
the vent, she needs a tracheostomy tube, a tie to secure the tube,
a continuous pulse-ox, an HME, a ventilator circuit, a ballard
suction catheter and suction canister, materials to perform her
trach care, and arterial blood gas kits.

11. Ventilator Settings
On 5/11/12, her ventilator settings were:
Mode: Assist Control
FIO2: 100%
Tidal Volume: 550ml
Set Rate: 14
Total Rate: 14
PEEP: 5 cmH2O
On 5/17/12, her ventilator settings were:
Mode: SIMV + PS
FIO2: 40%
Tidal Volume: 500ml
Set Rate: 10
Total Rate: 22
PEEP: 5
PS: 10 cmH2O
Diagnostic Testing
Lab Values
Actual Values
Normal Range

12. Interpretation
White Blood Cells
21,000
5,000-10,000
High
Red Blood Cells
3.05 million/cumm
4-6 million/cumm
Low
Hemoglobin
9.1gm
12-16gm
Low
Hematocrit
29.8%
40-50%
Low
Sodium
147mEq/l
135-145mEq/l
High
Potassium
3.6mEq/l
3.0-5.0mEq/l
Normal
Chloride
105mEq/l
85-100mEq/l
High
Blood Urea Nitrogen
44gm/dl
8-25gm/dl
High
Creatinine
1.56mEq/l
0.7-1.3mEq/l

13. High
Interpretation of Diagnostic Testing: The patient’s white blood
cell count it extremely high, in return making her red blood cell
count, hemoglobin, and hematocrit low. All of these values
were checked again on 5/17/12 and most of them were
improved. Her white blood cell count was back in normal
range, and her red blood cell count, hemoglobin and hematocrit
were still slightly under normal range, but improved from
5/11/12.
Arterial Blood Gas (Taken on 5/11/12)
At the time, the patient was on a ventilator at 100% FIO2.
Lab Values
Actual Values
Normal Range
Interpretation
pH
7.36
7.35-7.45
Normal
PaCO2
50mmHg
35-45mmHg
Acidic
HCO3
28mEq/l
22-26mEq/l
Alkaline
PaO2
60mmHg
80-100mmHg
Moderate Hypoxemia
Interpretation of arterial blood gas: The blood gas is a fully
compensated respiratory acidosis with moderate hypoxemia.
Another blood gas was done on 5/17/12 and it looked similar to

14. this one so due to her COPD, this probably is not too far from
normal for her and should not be worried about too much.
Physician’s Plan
Patient was started on diuretics for her CHF. Lasix was chosen.
A bronchoscopy was performed which showed methicillin
resistant staphyloccus aureus pneumonia. She was found to be
in acute renal failure so nephrology was consulted, her
medications were adjusted, and she then had a gradual
improvement in renal function. The patient was tried to be
weaned off the ventilator but failed so a tracheostomy was
placed by Dr. Hoskere on 4/13/12. She also had a percutaneous
endoscopic gastrostomy tube placed by Dr. Ampudia. He said
she had been having persistent diarrhea with negative
clostridium difficle stools a few weeks ago, and decided to start
her of Questran. The patient was then transferred to Select
Specialty Hospital for continuous pulmonary management as
well as medical management. Pulmonary was consulted to
decide what her ventilator needs were. She was supposed to
have ventilator checks every two hours. She was also ordered
to be weaned and adjusted as tolerated. As well as trach care
every shift, suction as needed, and to have her ventilator circuit
changed once a month. Repeat labs and further workups were
also ordered.
-Hospital Medications:
Coumadin (Warfarin)
5mg
Used to treat thromboembolic complications.
Humalog
3-15 units
Used to manage diabetes.
Lantus
26 units
Used to manage diabetes.
Prilosec (Omeprazole)

15. 20mg
Used for treatment of heartburn and other symptoms associated
with GERD.
Furosemide (Lasix)
60mg
Used as a diuretic due to CHF.
Levothyroxine (Levothroid)
150mcg
Used to manage hypothyroidism.
Lisinopril (Prinivil)
5mg
Used to manage hypertension
Lorazepam (Ativan)
1mg
Used to manage anxiety.
Metoprolol Tartrate (Lopressor)
25mg
Used to manage hypertension
Amiodarone (Cordarone)
200mg
Used to treat life threatening ventricular fibrillation.
Digoxin (Lanoxin)
125mg
Used to treat mild-moderate heart failure.
Fragmin (Dalteparin sodium)
120 IU/kg
Prophylaxis of ischemic complications in unstable angina.
Aldactone (Spironolactone)
25mg
Used for heart failure.
Nexium (esomeprazole magnesium)
40mg
Used for treatment and maintenance of erosive esophagitis due
to GERD.
Synthroid (Levothyroxine)
150mcg

16. Used to manage hypothyroidism.
Carafate (Sucralfate)
1g
Short term treatment of active duodenal ulcer.
ProAir (Albuterol Sulfate)
4 puffs
Used to treat bronchospasms.
Flovent (Fluticazone)
2 puffs
Used as a corticosteroid.
Prilosec (Omeprazole)
40mg
Used for treatment of heartburn and other symptoms associated
with GERD.
Zosyn (tazobactam sodium)
4.5g
Used for moderate community acquired pneumonia.
(PDR, 2012)
My Plan
The patient has improved quite a bit from the time she was
moved to the IMU on 5/11/12 as far as her ventilator settings
go. She is down to 40% FIO2 from 100% FIO2, she is now
breathing around twelve times per minute on her own as
opposed to not at all before, and she has been able to be
switched from assist control mode to SIMV with pressure
support. Therefore I would suggest continuing to wean her off
of the ventilator. I would first check all of the weaning
parameters including her maximum inspiratory pressure,
maximum expiratory pressure, vital capacity, and tidal volumes
to make sure she fell into the acceptable category. As long as
she did, I would start by decreasing her pressure support and
PEEP as tolerated. If she continued to do well weaning, I
would then start with two hours per day aerosol trach collar
weaning trials at around 40% FIO2 to 45% FIO2 and increase it
by a couple of hours each day until she could come off of the

17. ventilator completely. Eventually I would suggest she be
weaned off of the trach collar as well.
I would also suggest a follow up chest radiograph to find out if
there was a pleural effusion that had developed, and if so
continue with the necessary treatment of tapping it at the fourth
or fifth intercostals space mid axillary.
I think all home medications as well as hospital medications for
her co-morbidities should be continued during her stay,
especially the Lasix for her congestive heart failure to try and
improve the +2 to +3 pitting edema, and the bronchodilators for
her COPD.
Regarding the patient’s arterial blood gas, I would not change
much because her values are probably very normal for her. Her
PaCO2 is elevated but not to an extreme amount and her PaO2
shows moderate hypoxia which is not uncommon for a patient
with an obstructive lung disease. I would continue to monitor
this, but would not put a lot of emphasis on it unless the values
start to change.
Home Care
The patient will not return home but instead to Greystone
Nursing Facility, where she was originally brought from before
her fall. After she returns, as long as she was weaned and the
trach was removed before leaving BRMC, she will need to have
stoma care and possibly suctioning through her stoma
performed. She will most likely need a small amount of
supplemental oxygen as well.

18. Since the reason she was brought to BRMC in the first place
was due to a fall, I would suggest she be placed as a fall risk
patient at Greystone and be monitored carefully. I think she
would benefit from a walker and working with physical therapy
in order to hopefully prevent another fall, and possible
intubation.
Her medications for her co-morbidities that she was previously
taking before her stay in the hospital should be resumed or
continued.
References
Cardiomyopathy. (2012, May 24). Retrieved from
http://www.mayoclinic.com/health
/cardiomyopathy/DS00519/DSECTION=treatments-and-drugs
Downey, R., III. (2012, June 27). Obstructive Sleep Apnea.
Retrieved from http://emedicine.
medscape.com/article/295807-overview
Definition of Obesity. (2012, June 14). Retrieved from
http://www.medterms.com/script/main/
art.asp?articlekey=4607
Eltz, D. R., & Zieve, D. (2012). Diabetes. Retrieved from
http://www.ncbi.nlm.nih.gov/
Heartburn, Gastroesophageal Reflux (GER), and
Gastroesophageal Reflux Disease (GERD).
(2007, May). Retrieved from
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/
Kathuria, P. (2012). Chronic Kidney Disease. Retrieved from

19. http://www.emedicinehealth.com
/chronic_kidney_disease/article_em.htm
Kulick, D. L. (2012). Congestive Heart Failure. Retrieved from
http://www.medicinenet.com/
congestive_heart_failure/article.htm
Lukitsch, I. (2010, April 19). Hypernatremia Treatment and
Management. Retrieved from
http://emedicine.medscape.com/article/241094-treatment
Mathur, R. (2012). Hypothyroidism. Retrieved from
http://www.medicinenet.com/
hypothyroidism/page4htm.
Nabili, S. T. (2012). Anemia. Retrieved from
http://www.medicinenet.com/anemia/article.htm
PDR. (2012). Retrieved from http://www.pdr.net
Riaz, K. (2012, January 27). Hypertension Medication.
Retrieved from http://emedicine.
medscape.com/article/241381-medication
Thrombocytopenia. (2012, June 28). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000586.htm
Treatments for COPD. (2012, February 1). Retrieved from
http://www.rightdiagnosis.com/c/
copd/treatments.htm
Wilkins, R. L., Stoller, J. K., & Kacmarek, R. M. (2009).
Fundamentals of Respiratory Care.
Missouri: Mosby.
Clinical SOAP Assignment 2

20. Spring 2020 CPSC 3150
Background Information and HPI
Patient arrival- April 1, 2020 to a local level-1 trauma medical
center
Chief complaint(s)- dry nonproductive cough, shortness of
breath, general fatigue, loss of appetite, intermittent fever,
rhinorrhea
Age and gender- 45-year-old male, Caucasian
Smoking history- never been a smoker
Pulmonary history- no diagnosed lung disease
Height and weight- 5 foot 10 inches, 175 lbs.
Work history- assistant manager at a local grocery store
Home therapy- no home oxygen, Metformin, lisinopril, and
atorvastatin
Comorbidities- diabetes, hypertension, and hypertriglyceridemia
Subjective Information
Upon patient interview, the patient disclosed the following:
· Signs and symptoms of illness began four days prior to
seeking medical care
· Began as relatively mild but seems to be getting worse
· Cough is strong and frequent but nonproductive
· Feels like he cannot “catch his breath”
· Has not felt like doing much and called in sick to work
yesterday
· Some nausea leading to loss of appetite
· Treating low grade fever with Tylenol as needed
· Nasal secretions are clear and watery, patient associates with
seasonal allergies
· Patient denies any chest pain
· Has not been wearing a mask to work
Providers perform a thorough physical examination and
diagnostic testing.
Objective Information

21. Physical assessment- patient was alert to person, place, and
time; no cyanosis or clubbing noted; no pitting edema present;
normal body habitus; no signs of respiratory distress.
Inspection, palpation, and percussion revealed no chest
abnormalities.
Initial vital signs- BP 135/88, HR 110, RR 16, Temperature
99.5 F, Sp02 95% on RA
ECG- sinus tachycardia
CXR- Initial image on 4/1 demonstrated no acute changes
Bilateral breath sounds- rhonchi was heard bilaterally
ABG- pH 7.39, PaC02 42 mmHg, Pa02 80 mmHg, HC03 24, BE
0 on room air 4/1
Laboratory data- CBC, electrolytes, coagulation testing, liver
and renal function panel, C-reactive protein level, and lactate
was obtained. The following were considered abnormal:
· Lymphocytes 750/microliter
· Platelets 100,000/microliter
· C-reactive protein 3 mg/L
· Lactate 1.5 mmol/L
The patient was screened for influenza type A and B- both were
negative.
The patient was also swabbed for Covid-19 due to potential
community exposure with a real time reverse transcriptase-
polymerase chain reaction (rRT-PCR) assay (nasal and
pharyngeal). The patient was admitted for observation until the
results of the assay were confirmed/ruled out and placed in
droplet/airborne/contact isolation as a precaution.
The next day the results of the rRT-PCR confirmed the presence
of Covid-19 infection. The patient remained stable until repeat
examination and diagnostic testing on 4/7 revealed:
Vital signs- BP 140/90, HR 120, RR 28, Sp02 90% on RA
Bilateral breath sounds- crackles/rales heard in both lung bases
ABG- pH 7.35, PaC02 44 mmHg, Pa02 60 mmHg, HC03 22, BE
-2 on room air
CXR- bilateral patchy opacities indicative of atypical
pneumonia

22. Physician’s Plan
The patient was placed on supplemental oxygen at 2 liters/min
via nasal cannula. The following medications were given while
admitted to the hospital:
· Vancomycin
· Cefepime
· Remdesivir
· Guaifenesin
· Acetaminophen
· Intravenous normal saline
Continue to isolate the patient and monitor symptoms of Covid-
19. Report incidence to CDC and local health department.
Assessment and Plan
Based on the information provider, the student will follow the
SOAP guidelines and complete a narrative report of this case.
Remember to research and provide an interpretation for any
abnormalities, comorbidities, and medications. Please use this
opportunity to learn more about an emerging virus that you may
be tasked with treating in the future. Though we do not know
much, there is some evidence that will help support your
understanding of the disorder and provide guidance on the best
treatment options. Please include a description of when the
clinical manifestations turn severe and how the provider may
then incorporate more critical care strategies (mechanical
ventilation). Also, incorporate the role and importance of your
clinical competencies from this semester whenever appropriate
(which ones are indicated, contraindicated, etc.?).
Clinical SOAP Assignment Guidelines
To earn full credit, the student must do the following

23. Length
5-6 pages, not including title page or reference list
Spelling/grammar
APA
Little to no errors in spelling, grammar, or APA formatting
Timeliness
Submitted on or before the assigned due date
Background information & History of Present Illness
Described how the patient arrived, what facility the patient is
being seen in, the patient’s chief complaint, age and gender.
Smoking history in pack years, presence of pulmonary disease,
height, weight, IBW, work history or environmental exposure,
home oxygen, home medication list, comorbidities
Subjective information
Patient or family member responses to practitioner interview
Objective Information
Results of physical assessment, vital signs (HR, RR, Temp,
Sp02, BP), equipment settings, diagnostic testing. Be sure to
include sputum characteristics/culture, CXR or CT results,
breath sounds, ABG, lab data, ECG, mental status, PFT,
ventilator/Bipap settings, inspection, percussion, palpation,
hemodynamic measurements
Assessment/
professional judgment
Provide possible explanations or interpretations for each
abnormal piece of data collected based on evidence-based
practice
Plan of action
Provide both the physician’s plan as well as your

24. recommendations for the continued care of this patient; provide
rationale as appropriate. Include any relevant therapeutic
objectives you wish to obtain.
Accuracy and completeness of information
All information should be factual, calculations should be
correct, and a thorough description of all medications,
conditions, should be included.