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ALLERGIES/ADR

MRT5 – Allergies/ADRs

FACILITY ALLERGY/ADR

No Remote Allergy/ADR Data available for this patient

LOMA LINDA HCS No Known Allergies

MEDICATIONS

MRR1 – Med Reconciliation

INCLUDED IN THIS LIST: Alphabetical list of active outpatient

prescriptions dispensed from this VA (local) and dispensed from another

VA or DoD facility (remote) as well as inpatient orders (local pending and

active), local clinic medications, locally documented non-VA medications,

and local prescriptions that have expired or been discontinued in the past

90 days.

Non-VA Meds Last Documented On: May 06, 2022

*

***NOTE*** The display of VA prescriptions dispensed from another VA or

DoD facility (remote) is limited to active outpatient prescription entries

matched to National Drug File at the originating site and may not include

some items such as investigational drugs, compounds, etc.

NOT INCLUDED IN THIS LIST: Medications self-entered by the patient into

personal health records (i.e. My HealtheVet) are NOT included in this

list. Non-VA medications documented outside this VA, remote inpatient

orders (regardless of status) and remote clinic medications are NOT

included in this list. The patient and provider must always discuss

medications the patient is taking, regardless of where the medication was

dispensed or obtained.

–

INPT ACETAMINOPHEN 325MG TAB U/D (Status=Active)

650MG BY MOUTH EVERY FOUR HOURS AS NEEDED For mild

pain (1-3)/HA/Temperature>101.4F **DO NOT TAKE MORE

THAN 3000MG OF ACETAMINOPHEN PER DAY** Indication:

FEVER

OUTPT ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL (Status = Active)

INHALE 2 PUFFS BY MOUTH EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF

BREATH

Rx# 11761293 Last Released: 5/22/25 Qty/Days Supply: 2/30

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: FOR SHORTNESS OF BREATH

INPT ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3ML (Status=Active)

1 VIAL INHL EVERY SIX HOURS RESPIRATORY While awake

Indication: FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE

OUTPT ATENOLOL 50MG TAB (Status = Discontinued)

TAKE ONE TABLET BY MOUTH DAILY FOR BLOOD PRESSURE AND HEART RATE

CONTROL

Rx# 10378684C Last Released: 3/6/25 Qty/Days Supply: 90/90

Rx Expiration Date: 3/1/26 Refills Remaining: 3

OUTPT BUDESONIDE 160/FORMOTER 4.5MCG 120D INH (Status = Active)

INHALE 2 PUFFS BY MOUTH TWICE A DAY FOR CHRONIC OBSTRUCTIVE

PULMONARY DISEASE **APPROVED TO REPLACE WIXELA**

Rx# 11550594 Last Released: 6/9/25 Qty/Days Supply: 3/90

Rx Expiration Date: 8/17/25 Refills Remaining: 0

Indication: FOR BRONCHOSPASM COPD

CLIN CEFEPIME HCL 2GM/NS 100ML INJ,SOLN (Status=Discontinued)

CEFEPIME INJ,PWDR 2 GM in SODIUM CHLORIDE 0.9% INJECT

50 ml IVPB INFUSE OVER 30 Minutes ONE-TIME STAT

Administer in ED. Indication: ASDFASF <ORDER

DISCONTINUED>

CLIN CEFEPIME INJ,PWDR (Status=EXPIRED)

Change CEFEPIME INJ,PWDR 2 GM in SODIUM CHLORIDE 0.9%

INJECT 100 ml IVPB INFUSE OVER 30 Minutes ONE-TIME

STAT Administer in ED. Indication: ASDFASF

BCMA ORDER LAST ACTION: 06/12/25 23:26 GIVEN

INPT CEFEPIME INJ,PWDR (Status=Pending)

CEFEPIME INJ,PWDR 2 GM in IVPB EVERY EIGHT HOURS STAT

Proven infection. Organism: Give for 7 days Weight:

• 9 lb [97.48 kg] (05/22/2025 14:44) Height: 71 in

[180.3 cm] (07/11/2019 13:53) Creatinine: 06/12/25

CREATININE,SERUM 1.01 Indication: FOR PNEUMONIA

Non-VA CETIRIZINE HCL 10MG TAB

TAKE ONE TABLET BY MOUTH DAILY May 06, 2022

OUTPT DIAZEPAM 10MG TAB (Status = Active)

TAKE ONE TABLET BY MOUTH TWICE A DAY AS NEEDED ANXIETY HOLD FOR

SEDATION

Rx# 11761321 Last Released: 5/22/25 Qty/Days Supply: 28/14

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: ANXIETY

INPT DOCUSATE NA 250MG CAP UD (Status=Active)

250MG BY MOUTH DAILY AS NEEDED Indication: FOR

CONSTIPATION

OUTPT EMPAGLIFLOZIN 25MG TAB (Status = Active)

TAKE ONE-HALF TABLET BY MOUTH DAILY FOR CHRONIC HEART FAILURE

Rx# 11761296 Last Released: 5/22/25 Qty/Days Supply: 15/30

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: FOR CHRONIC HEART FAILURE

INPT EMPAGLIFLOZIN 12.5MG HALF-TAB UD (Status=Active)

• 5MG BY MOUTH DAILY Indication: FOR CHRONIC HEART

FAILURE

OUTPT FUROSEMIDE 40MG TAB (Status = Active)

TAKE ONE TABLET BY MOUTH DAILY AS NEEDED EDEMA (HOLD FOR SYSTOLIC

BLOOD PRESSURE LESS THAN <95 MMHG) WATER PILL

Rx# 11761300 Last Released: 5/22/25 Qty/Days Supply: 30/30

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: EDEMA

INPT GUAIFENESIN 400MG TAB (Status=Pending)

400MG BY MOUTH THREE TIMES A DAY AS NEEDED

Indication: FOR COUGH

CLIN LEVALBUTEROL HCL 0.63MG/3ML INHL SOLN (Status=EXPIRED)

• 63MG/3ML INHL ONE-TIME STAT Indication: ASDFASDF

BCMA ORDER LAST ACTION: 06/12/25 21:48 GIVEN

Non-VA MAGNESIUM OXIDE 400MG TAB

TAKE ONE TABLET BY MOUTH DAILY Jul 29, 2019 **NOTICE:

OTC ITEM – NO FURTHER FILLS ALLOWED** product

INPT METHYLPREDNISOLONE ACET 40MG/ML 1ML VI (Status=Active)

40MG/1ML INTRAMUSCULARLY EVERY EIGHT HOURS

Indication: CHRONIC OBSTRUCTIVE PULMONARY DISEASE

EXACERBATION

OUTPT METOPROLOL SUCCINATE 25MG SA TAB (Status = Active)

TAKE THREE TABLETS BY MOUTH DAILY AFIB (HOLD FOR SYSTOLIC BLOOD

PRESSURE LESS THAN <100 OR HEART RATE LESS THAN <55)

Rx# 11761307 Last Released: 5/22/25 Qty/Days Supply: 60/20

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: AFIB

INPT METOPROLOL SUCCINATE 25MG SA TAB (Status=Active)

75 MG BY MOUTH DAILY Indication: AFIB

INPT ONDANSETRON HCL 2MG/ML INJ 2ML VI (Status=Active)

4MG/2ML IV EVERY SIX HOURS AS NEEDED Indication:

NAUSESA

OUTPT PREDNISONE 20MG TAB (Status = Active)

TAKE TWO TABLETS BY MOUTH DAILY COPD EXCERBATION

Rx# 11761317 Last Released: 5/22/25 Qty/Days Supply: 10/5

Rx Expiration Date: 6/21/25 Refills Remaining: 0

Indication: COPD EXCERBATION

OUTPT RIVAROXABAN 20MG TAB (Status = Discontinued)

TAKE ONE TABLET BY MOUTH DAILY WITH LARGEST MEAL OF THE DAY FOR

BLOOD CLOT PREVENTION*APPROVED*

Rx# 9375454F Last Released: 12/12/24 Qty/Days Supply: 90/90

Rx Expiration Date: 5/9/25 Refills Remaining: 1

OUTPT RIVAROXABAN 20MG TAB (Status = Active)

TAKE ONE TABLET BY MOUTH DAILY WITH LARGEST MEAL OF THE DAY FOR

BLOOD CLOT PREVENTION*APPROVED*

Rx# 9375454G Last Released: 5/27/25 Qty/Days Supply: 90/90

Rx Expiration Date: 8/20/25 Refills Remaining: 0

INPT RIVAROXABAN 20MG TAB (Status=Active)

20MG BY MOUTH DAILY Indication: FOR PREVENTION OF

BLOOD CLOTS

OUTPT SIMVASTATIN 10MG TAB (Status = Active)

TAKE ONE TABLET BY MOUTH AT BEDTIME FOR HIGH CHOLESTEROL

Rx# 10869620C Last Released: 3/5/25 Qty/Days Supply: 90/90

Rx Expiration Date: 11/16/25 Refills Remaining: 2

Indication: FOR HIGH CHOLESTEROL

INPT SIMVASTATIN 10MG TAB (Status=Active)

10MG BY MOUTH AT BEDTIME Indication: FOR HIGH

CHOLESTEROL

CLIN SODIUM CHLORIDE 0.9% INJ (Status=Discontinued)

SODIUM CHLORIDE 0.9% INJECT 250 ml IV 250 ml/hr STAT

To be administered in the ED. Indication: ASDFAS

<AUTO DC>

BCMA ORDER LAST ACTION: 06/12/25 21:30 INFUSING

CLIN VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=Discontinued)

Discontinue VANCOMYCIN 5MG/ML PREMIX BAG INJECT 350

ml IVPB INFUSE OVER 180 MINUTES ONE-TIME STAT

Indication: ASDFASDF <ORDER DISCONTINUED>

CLIN VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=EXPIRED)

Change VANCOMYCIN 5MG/ML PREMIX BAG INJECT 400 ml

IVPB INFUSE OVER 180 MINUTES NOW STAT Indication

ASDFASDF

BCMA ORDER LAST ACTION: 06/12/25 23:26 GIVEN

INPT VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=Pending)

VANCOMYCIN 5MG/ML PREMIX BAG INJECT 250 ml IVPB

INFUSE OVER 150 Minutes EVERY TWELVE HOURS Vancomycin

dosing per P&T Approved Pharmacy Protocol Indication:

• High Risk for MRSA due to MRSA colonizer or on IV

antibiotic w/in 90 days Duration of therapy: 7 days

NEW Therapeutic target for all indications

AUC/MIC-24 (aka. AUC24) = 400-600 hr*mg/L Is patient

less than 52 years of age and of female birth sex?*

No Is patient able to conceive?* N/A patient is >= 52

years old and/or not of female birth sex as above

Indication: FOR PNEUMONIA

–

SUPPLIES

–

=

MEDICATION HISTORY

=

Local and Remote Allergies/ADRs were reviewed and confirmed with

patient/caregiver? YES

Were remote allergies found upon review? see above

VALL/DOD Active Outpatient Medications were reviewed with patient/caregiver?

YES

Non-VA Medications were discussed with patient/caregiver?: YES

Remote VA Medications were discussed with patient/caregiver?: YES

Essential Medication List for review (EMLR) has been reviewed with

patient/caregiver? YES

Refill history reviewed with patient/caregiver?: YES

=

MEDICATION REVIEWED

=

MEDICATION INTAKE HISTORY ADMISSION ASSESSMENT

Patient is a 78 y.o. MALE seen in the Emergency Department today. Medication

intake history conducted at this encounter.

Patient is being admitted to . Interviewed patient to complete medication

reconciliation and fill medications needing refills. Patient is actively

taking these medication unless otherwise note.

Source of Information: Patient son

Spoke with the patient/caregiver at the ED bedside. Patient was verified

with two ID’s. YES

New Allergies/ADRs found?: NO

=

HOME MEDICATIONS & DISCREPANCIES

=

• ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL INHALE 2 PUFFS BY ACTIVE

MOUTH EVERY 4 HOURS AS NEEDED

Indication: FOR SHORTNESS OF BREATH

• BUDESONIDE 160/FORMOTER 4.5MCG 120D INH INHALE 2 PUFFS BY ACTIVE

MOUTH TWICE A DAY FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE

**APPROVED TO REPLACE WIXELA**

Indication: FOR BRONCHOSPASM COPD

• DIAZEPAM 10MG TAB TAKE ONE TABLET BY MOUTH TWICE A DAY AS ACTIVE**

NEEDED HOLD FOR SEDATION

Indication: ANXIETY

• EMPAGLIFLOZIN 25MG TAB TAKE ONE-HALF TABLET BY MOUTH DAILY ACTIVE

Indication: FOR CHRONIC HEART FAILURE

• FUROSEMIDE 40MG TAB TAKE ONE TABLET BY MOUTH DAILY AS NEEDED ACTIVE

(HOLD FOR SYSTOLIC BLOOD PRESSURE LESS THAN <95 MMHG) WATER

PILL

Indication: EDEMA

• METOPROLOL SUCCINATE 25MG SA TAB TAKE THREE TABLETS BY MOUTH ACTIVE

DAILY (HOLD FOR SYSTOLIC BLOOD PRESSURE LESS THAN <100 OR

HEART RATE LESS THAN <55)

Indication: AFIB

• PREDNISONE 20MG TAB TAKE TWO TABLETS BY MOUTH DAILY ACTIVE

Indication: COPD EXCERBATION

• RIVAROXABAN 20MG TAB TAKE ONE TABLET BY MOUTH DAILY WITH ACTIVE**

LARGEST MEAL OF THE DAY FOR BLOOD CLOT PREVENTION*APPROVED*

• SIMVASTATIN 10MG TAB TAKE ONE TABLET BY MOUTH AT BEDTIME ACTIVE**

Indication: FOR HIGH CHOLESTEROL

78 years old male patient presented with afib, shortness of breath; patient’s

son over the phone reports that

a) patient takes above home meds as ordered, but has NOT taken any medication

today, 6/12; also, patient took the last dose of rivaroxaban 3 days ago and

simvastatin 2 days ago.

b) patien takes amoxillin, prednisone, and levalbuterol neb from nonVA provider.

c) patient was found with an empty diazepam bottle around 1pm on 6/12, and is

suspected to have taken >10 pills of diazepam prior to OSH ER visit.

No new allergy reported, OTC includes cetirizine, mag, potassium, mucinex; no

refill requested today.

PBM PharmD Pharmacotherapy Rem V12

Address adherence

Medication monitoring or diagnostic evaluation (e.g., other labs, EKG)

Medication reconciliation (changes to active VA and non-VA medication lists

to reconcile differences)

No changes to medication lists made (medication review completed, no

discrepancies identified)

Prevent or manage an adverse drug reaction or event

Inpatient Clinical Pharmacist

Indwelling Urinary Catheter

Is the patient allergic to?

Latex

NO

Povidone iodine

NO

Were alternatives to indwelling urinary catheters considered prior to

insertion? Yes

Is there an order for insertion?

Yes

Indication for insertion

Acute urinary retention or bladder outlet obstruction

2nd Verifier: TRISH RN

Time Inserted: 2340PM

Date Inserted

Date: June 12, 2025

Scheduled Replacement

Pre-insertion care

Bladder scan completed prior to insertion

Result: 652 ML

Peri-care performed

Hand hygiene performed

Yes

Insertion care

Sterile peri-urethral cleaning performed

Balloon inflation amount: 10 ML

Any resistance noted?

No

Urine return noted?

YES

Output: 150ml

Urine Character

cloudy, hazy

Material of Foley

Silastic

Type of Foley

Straight

Catheter size (Fr)

16

Tamper seal intact?

Yes

Patient tolerated procedure well?

Yes

Immediate post-insertion care

Catheter properly secured to patient

Position drainage bag below the bladder

Maintain a closed drainage system

Education provided on

Click here for FAQs Catheter Associated Urinary Tract Infection

-indication for use

-importance of securing catheter

-maintaining closed system

-keeping bag below the bladder

-catheter care

-symptoms of CAUTI (fever, chills, new confusion/weakness, new lower

abdominal/flank/testicular/prostate pain, or discharge (pus) around

catheter)

PATIENT/FAMILY EDUCATION: Level of understanding: Good

STAFF NURSE

Receipt Acknowledged By

06/17/2025 19: 13 /es/ ROSBEL IVY AMBAAN

BSN RN

ED/NURSING NOTE Has ADDENDA

ASSUMED CARE AND INTRODUCTION TO PT AT: 2050

Patient identification band on: WRIST

Patient identification band validated by writer of this note

PROBLEM: xfer from barstow, afib, sob, copd

–

SUBJECTIVE

–

PSYCHOSOCIAL / COMMUNICATION SYSTEM

WNL: Affect, appearance, behavior, speech appropriate to age and situation

NEUROLOGICAL SYSTEM

Within Normal Limits (A&O x 4, follows commands, speaks clearly, responds to

visual/auditory stimuli)

CARDIO-VASCULAR SYSTEM

Within Normal Limits no cyanosis/edema, extremities warm to touch

RESPIRATORY SYSTEM

DV: 2l o2 via NC, sob, non productive cough

GASTRO-INTESTINAL / NUTRITIONAL SYSTEM

Within Normal Limits (Soft abdomen, no distension, continent, appetite: good

to

fair)

GENITO-URINARY SYSTEM

Within Normal Limits (Voids clear yellow urine, continent, voids without

difficulty)

MUSCULO – SKELETAL SYSTEM

Within Normal Limits (Able to move all extremities, normal coordination /

gait)

INTEGUMENTARY SYSTEM

DV: bruising bilat arms, left scalp

PATIENT/FAMILY EDUCATION DOCUMENTATION

Barriers to Learning: None

Readiness to Learn: Ready to learn

Learning Preference: Verbal

Instruction given to: Patient

Topics discussed: Disease Process, Medications

Teaching Method Used: Discussion

Assessment of Learning: Good

Understanding measured by: Verbalization

Psych

Has anyone been hurting you physically or emotionally? No

Do you suspect that this patient may be a perpetrator or victim of abuse? No

Are you feeling hopeless about the present or future? No

Have you had thoughts about taking your life? No

Do you have a plan to take your life? No

Have you ever had a suicide attempt? No

Is the patient homicidal? No

–

(I) INTERVENTIONS

–

CARDIAC MONITOR: 2055

SPO2 MONITOR: 2055

NIBP MONITOR: 2055

INTRAVENOUS ACCESS: 18g LFA, 20g rt hand

–

SUBSEQUENT VITAL SIGNS

TIME BP PULSE RESP O2% TEMP PAIN

cprs

–

–

MEDICATION ADMINISTRATION

TIME MEDICATION DOSE ROUTE

bcma

2230 vancomycin 2gm per dr zaidi ivpb

pharmacist delay to clear meds, dr zaidi informed.

–

INTRAVENOUS FLUIDS

TIME SOLUTION VOLUME RATE/BOLUS

bcma

–

NARRATIVE

–

2045: pt biba, xfer from barstow comm ed for afib and sob/copd exacerbation.

pt calm quiet cooperitive, gcs 15 a/ox4, respirations even, shallow,

unlabored, non productive cough, speaking in 2-7 word senctences, 2L o2 via NC

“as needed” per pt, skin warm and dry, mucous membranes moist, no distress,

ekg completed, placed on cardiac monitor, labs drawn and sent per md orders.

dr zaidi at bedside for eval.

2101: radiology at bedside for portable chest film, pt tolerated well, no

distress, rmains on cardiac monitor.

2142: RT at bedside for breathing tx, tolerated well, no distress, on cardiac

monitor.

2201: dr zaidi at bedside for re-eval.

2243: bing pharmaicist at bedsdie for eval.

2245: sbar to irene rn. pt remains resting comfortably in gurney, gcs 15 a/ox4,

respirations even and unlabored, 2l o2 via NC, unproductive cough, skin warm and

dry, no distress, on cardiac monitor.

RN

WELL 02 INH 2L/NC. PT A/O X 3, CONVERSANT, BREATHING LABORED DURING

STAFF NURSE

Patient Seen on JUN 12, 2025

78-year-old male history of COPD atrial fibrillation status post dual-chamber

pacemaker on blood thinner, presents as a transfer from Barstow community

Hospital due to concern for acute hypoxic respiratory failure. Patient was

found down at home at around 8 AM after taking about 11 diazepam as patient was

tired of dealing with his chronic illnesses however denies SI, states that he

just wanted to relax, was found down at around 8 AM, hypoxic to 72%, placed on

CPAP, brought to the ER, was given nebulizer treatments, approximately 3?4, had

cardiac evaluation with negative troponin however noted to be in atrial

fibrillation with RVR,

ROS: As per HPI the rest of 10×2 systems are negative

PMHx

Atrial fibrillation (SCT 49436004)

Chronic obstructive lung disease (SCT 13

Hyperlipidemia (SCT 55822004)

Anxiety (SCT 48694002)

History of alcohol abuse (SCT 371434005)

Allergic rhinitis (SCT 61582004)

Hearing Loss (SCT 15188001)

Tinnitus (SCT 60862001)

SHx: denies active drug use, see HPI

All: Patient has answered NKA

MEDS

BUDESONIDE 160/FORMOTER 4.5MCG 120D INH

INHALE 2 PUFFS BY MOUTH TWICE A DAY FOR CHRONIC OBSTRUCTIVE PULMONARY

ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL

INHALE 2 PUFFS BY MOUTH EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF

EMPAGLIFLOZIN 25MG TAB

TAKE ONE-HALF TABLET BY MOUTH DAILY FOR CHRONIC HEART FAILURE

FUROSEMIDE 40MG TAB

TAKE ONE TABLET BY MOUTH DAILY AS NEEDED EDEMA (HOLD FOR SYSTOLIC

METOPROLOL SUCCINATE 25MG SA TAB

TAKE THREE TABLETS BY MOUTH DAILY AFIB (HOLD FOR SYSTOLIC BLOOD

PREDNISONE 20MG TAB

TAKE TWO TABLETS BY MOUTH DAILY CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXCERBA

DIAZEPAM 10MG TAB

TAKE ONE TABLET BY MOUTH TWICE A DAY AS NEEDED ANXIETY HOLD FOR

RIVAROXABAN 20MG TAB

TAKE ONE TABLET BY MOUTH DAILY WITH LARGEST MEAL OF THE DAY FOR BLOOD

SIMVASTATIN 10MG TAB

TAKE ONE TABLET BY MOUTH AT AT BEDTIME FOR HIGH CHOLESTEROL

O: Vitals :

• 9 F [36.6 C] (06/12/2025 20:50)

111/66 (06/12/2025 20: 50)

122 (06/12/2025 20: 50)

22 (06/12/2025 20: 50)

96% (06/12/2025 20:50)

(Normal)

Gen: Alert, awake, oriented x 3, in mild distress

HEENT: Perrla, eomi, no icterus

CV: regular not tachycardic

LUNG: no acute respiratory distress, congested chest with wheezing

ABD: soft non distended no peritoneal signs

EXT: +1 pitting edema of bilateral lower extremity

NEURO: no focal deficit, extremity strength equal, no focal cranial nerve

findings

LABS

Report Released Date/Time

Provider: SMITHWICK,JULIE

Specimen: SERUM. DX 0613 48

Specimen Collection Date: Jun 13, 2025

Test name Result units Ref. range Site Code
CREATININE_SERUM (eGFR) Collected - Specimen In Lab
MAGNESIUM Collected - Specimen In Lab
CMP Collected - Specimen In Lab

=

Report Released Date/Time: Jun 13, 2025@05:48

Provider: SMITHWICK,JULIE

Specimen: BLOOD. HE 0613 34

Specimen Collection Date: Jun 13, 2025

Test name Result units Ref. range Site Code
WBC 5.35 K/uL 4.00 - 10.00 [605]
RBC 3.29 L M/uL 4.40 - 5.70 [605]
HGB 10.0 L g/dL 13.5 - 17.5 [605]
HCT 30.9 L % 40.0 - 53.0 [605]
MCV 93.9 fL 80.0 - 100.0 [605]
MCH 30.4 pg 27.6 - 33.3 [605]
MCHC 32.4 g/dL 32.0 - 35.0 [605]
RDW-SD 60.5 H fL 35.1 - 43.9 [605]
PLT 173 K/uL 150 - 450 [605]
MPV 9.1 fL 8.8 - 11.8 [605]

Neutrophils (AUTO) 4.54 K/uL 2.50 – 7.00 [605]

Lymphocytes (AUTO) 0.45 L K/uL 0.90 – 3.00 [605]

Monocytes (AUTO) 0.29 K/uL 0.20 – 1.00 [605]

Eosinophils (AUTO) 0.00 K/uL 0.00 – 0.50 [605]

Basophils (AUTO) 0.01 K/uL 0.00 – 0.10 [605]

IG (AUTO) 0.06 H K/uL 0.00 – 0.03 [605]

NRBC (AUTO) 0.00 K/uL [605]

=

Report Released Date/Time

Provider: SMITHWICK,JULIE

Specimen: URINE. SERO 0613 4

Specimen Collection Date: Jun 13, 2025@03:20

Test name Result units Ref. range Site Code
LEGIONELLA AG Collected - Specimen In Lab

=

Report Released Date/Time: Jun 13, 2025@05:10

Provider: ZANG,BIN

Specimen: NARES. SERO 0613 6

Specimen Collection Date: Jun 13, 2025@02:00

Test name Result units Ref. range Site Code

MRSA SURVL NARES DNA (ADMIT)Negative Ref: Negative [605]

Eval: POSITIVE: MRSA DNA detected, MRSA nasal colonization

Eval: NEGATIVE: No MRSA DNA detected, MRSA nasal colonization unlikely

Eval: UNRESOLVED: Unresolved-inhibitory specimen. Please Repeat.

=

Report Released Date/Time: Jun 12, 2025@22:42

Provider: ZAIDI,ADNAN

Specimen: PLASMA. DX 0612 849

Specimen Collection Date: Jun 12, 2025@22:20

Test name Result units Ref. range Site Code

LACTIC ACID 1.6 mMol/L 0.5 – 2.2 [605]

=

MICROBIOLOGY

Accession [UID]: BC 25 2937 [K725002937] Received: Jun 12, 2025@22:29

Collection sample: BLOOD CULTURE BOTTLE (BLOOD)Collection date: Jun 12, 2025

22: 20

Site/Specimen: BLOOD

Provider: ZAIDI,ADNAN

Comment on specimen

BLOOD CULTURE BOTTLE VOLUME SUB OPTIMAL.RECOLLECT. RAC RN J.P

Test(s) ordered: BLOOD CULTURE; BLOOD

=

MICROBIOLOGY

Accession [UID]: BC 25 2938 [K725002938] Received: Jun 12, 2025@22:31

Collection sample: BLOOD CULTURE BOTTLE (BLOOD)Collection date: Jun 12, 2025

22: 00

Site/Specimen: BLOOD

Provider: ZAIDI,ADNAN

Comment on specimen

BLOOD CULTURE BOTTLE VOLUME SUB OPTIMAL.RECOLLECT. LAC RN J.P

Test(s) ordered: BLOOD CULTURE; BLOOD

=

Report Released Date/Time: Jun 12, 2025@21:58

Provider: ZAIDI,ADNAN

Specimen: SERUM. DX 0612 844

Specimen Collection Date: Jun 12, 2025@21:20

Test name Result units Ref. range Site Code

ACETAMINOPHEN <10.0 ug/mL 10 – 30 [605]

Eval: Toxic range is greater than 300 ug/mL

SALICYLATE <4.0 mg/dL 10 – 30 [605]

Eval

Eval: Toxic range begins at 30 mg/dL.

Eval: Intoxication: > 50 mg/dL.

Eval: Lethal levels usually begin at >60 mg/dL.

=

Report Released Date/Time: Jun 12, 2025@21:13

Provider: ZAIDI,ADNAN

Specimen: BLOOD. HE 0612 490

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code
WBC 6.10 K/uL 4.00 - 10.00 [605]
RBC 3.59 L M/uL 4.40 - 5.70 [605]
HGB 10.9 L g/dL 13.5 - 17.5 [605]
HCT 32.9 L % 40.0 - 53.0 [605]
MCV 91.6 fL 80.0 - 100.0 [605]
MCH 30.4 pg 27.6 - 33.3 [605]
MCHC 33.1 g/dL 32.0 - 35.0 [605]
RDW-SD 60.2 H fL 35.1 - 43.9 [605]
PLT 179 K/uL 150 - 450 [605]
MPV 9.1 fL 8.8 - 11.8 [605]

Neutrophils (AUTO) 5.71 K/uL 2.50 – 7.00 [605]

Lymphocytes (AUTO) 0.23 L K/uL 0.90 – 3.00 [605]

Monocytes (AUTO) 0.09 L K/uL 0.20 – 1.00 [605]

Eosinophils (AUTO) 0.00 K/uL 0.00 – 0.50 [605]

Basophils (AUTO) 0.01 K/uL 0.00 – 0.10 [605]

IG (AUTO) 0.06 H K/uL 0.00 – 0.03 [605]

NRBC (AUTO) 0.00 K/uL [605]

=

Report Released Date/Time: Jun 12, 2025@21:45

Provider: ZAIDI,ADNAN

Specimen: PLASMA. CEN 0612 386

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code

B-TYPE NATRIURETIC PEPTIDE 131.6 H pg/mL <2.0 – 100.0 [605]

Eval: LLVAMC uses the Siemens BNP methodology.

Eval: BNP results should not be used interchangeably with other

Eval: Manufacture’s BNP assays, nor with any NT-proBNP results.

=

Report Released Date/Time: Jun 12, 2025@21:34

Provider: ZAIDI,ADNAN

Specimen: PLASMA. CEN 0612 385

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code

TROPONIN I HS 11 ng/L <3 – 57 [605]

=

Report Released Date/Time: Jun 12, 2025@21:28

Provider: ZAIDI,ADNAN

Specimen: PLASMA. COAG 0612 109

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code
PT 14.1 sec 11.7 - 14.4 [605]

INR 1.08 [605]

Eval: ACCURACY OF INR AT LEVELS >5.5 ARE DECREASED.

Eval: TARGET INR:

Eval: Prophylaxis of deep venous thrombosis 2.0-3.0

Eval: In high-risk medical or surgical patients.

Eval: Treatment of deep venous thrombosis. 2.0-3.0

Eval: Prevention of embolism. 2.0-3.0

Eval: Prevention of recurrent embolism, or 3.0-4.5

Eval: Patients with mechanical prosthetic

Eval: Intravascular valves.

PTT 30.7 sec 24.7 - 35.3 [605]

Eval: THERAPEUTIC RANGE IS 82.0 – 108.0 SECONDS

Eval: THERAPEUTIC RANGE Prior to 4/24/18 is 60.0 – 94.0 SECONDS

Comment: Heparin therapeutic PTT range for current lot is 82-108 sec.

=

Report Released Date/Time: Jun 12, 2025@21:26

Provider: ZAIDI,ADNAN

Specimen: SERUM. DX 0612 835

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code
SODIUM 133 L mMol/L 136 - 144 [605]
POTASSIUM 3.5 L mMol/L 3.6 - 5.1 [605]
CHLORIDE 92 L mMol/L 101 - 111 [605]
CO2 24.0 mMol/L 22 - 32 [605]

UREA NITROGEN 12 mg/dL 8 – 20 [605]

CREATININE 1.01 mg/dL .64 - 1.27 [605]

eGFR >60 mL/min Ref: >=60 [605]

Eval: As of 04/04/2022: using 2021 CKD-EPI Creatinine Equation.

Eval: From 08/10/21-4/4/2022: using 2012 CKD-EPI Creatinine Equation.

Eval: Prior to 08/10/21: using the MDRD Equation.

GLUCOSE 142 H mg/dL 74 - 118 [605]
CALCIUM 8.6 L mg/dL 8.9 - 10.3 [605]
ALBUMIN 2.8 L gm/dL 3.5 - 4.8 [605]

TOT. BILIRUBIN 1.7 H mg/dL 0.2 – 1.2 [605]

ALKALINE PHOSPHATASE 43 IU/L 32 – 91 [605]

ALT 23 IU/L 17 - 63 [605]
AST 39 IU/L 15 - 41 [605]
CPK 519 H IU/L 49 - 397 [605]

AGAP (UI) 17.0 H 3 – 11 [605]

PROTEIN TOTAL 5.6 L gm/dL 6.1 – 7.9 [605]

Comment: eGFR CKD-EPI

Estimated Glomerular Filtration Rate (eGFR) calculated using the

2021 Chronic Kidney Disease-Epidemiology (CKD-EPI) Collaboration

creatinine equation; units of measure are mL/min/1.73 m2.

Results are only valid for adults (>=18 years) whose serum

creatinine is in a steady state. eGFR calculations are not valid

for patients with acute kidney injury and for patients on dialysis.

Creatinine-based estimates of kidney function may also be

inaccurate in patients with reduced creatinine generation due to

decreased muscle mass (e.g., malnutrition, severe hypoalbuminemia,

sarcopenia, chronic neuromuscular disease, amputations, severe

heart failure or liver disease) and in patients with increased

creatinine generation due to increased muscle mass (e.g., muscle

builders, anabolic steroids) or increased dietary intake.

As drug clearance is proportional to total GFR and not GFR indexed

to body surface area (BSA), in individuals with a BSA substantially

different than 1.73 m2, drug dosing should be based on the reported

eGFR value de-indexed from BSA by multiplying by the individual’s

BSA and dividing by 1.73.

CKD is diagnosed based on abnormalities of kidney structure or

function, present for >3 months, with implications for health and

disease. CKD is classified and staged based on cause, eGFR and

albuminuria (quantified as urine albumin to creatinine ratio). An

eGFR >60 mL/min/1.73 m2 in the absence of increased urine albumin

excretion or structural abnormalities does not represent CKD.

eGFR

(mL/min/1.73 m2) CKD stage Interpretation

>=90 G1 Normal

60-89 G2 Mild decrease

45-59 G3A Mild to moderate decrease

30-44 G3B Moderate to severe decrease

15-29 G4 Severe decrease

<15 G5 Kidney failure

=

Report Released Date/Time: Jun 12, 2025@21:30

Provider: ZAIDI,ADNAN

Specimen: SERUM. IMM 0612 262

Specimen Collection Date: Jun 12, 2025@21:00

Test name Result units Ref. range Site Code
PROCALCITONIN 0.15 H ng/mL Ref: <=0.05 [605]

Eval: -A concentration < 0.5 ng/mL represents a low risk of severe

Eval: sepsis and/or septic shock.

Eval: -Concentrations < 0.5 ng/mL do not exclude an infection,

Eval: such as localized infections which can be associated with

Eval: such low concentrations, or a systemic infection in its initial

Eval: stages.

Eval: -A concentration > 2 ng/mL represents a high risk of severe sepsis

Eval: and/or septic shock.

Eval: -Increased procalcitonin (PCT) can occur without infection. PCT

Eval: concentrations between 0.5 and 2.0 ng/mL should be interpreted

Eval: considering the patient’s history.

Eval: -It is recommended to retest PCT within 6-24 hours if any

Eval: concentrations > 2 ng/mL are obtained.

=

Performing Lab Sites

[605] LOMA LINDA HCS [CLIA# 05D0988208]

11201 BENTON ST 11201 Benton Street LOMA LINDA, CA 92357-1000

=

CHEST SINGLE VIEW

Exm Date: JUN 12, 2025@21:00

Req Phys: ZAIDI,ADNAN Pat Loc: 4NW/06-13-2025@06:18

Img Loc: LL/3RD FLOOR LOCATION A

Service: Unknown

LOMA LINDA HCS

LOMA LINDA, CA 92357

909-825-7084

(Case 605-061225-577 COMPLETE) CHEST SINGLE VIEW (RAD Detailed)

CPT: 71045

Reason for Study: dyspnea cough

Clinical History

Report Date Reported: JUN 12, 2025

Date Verified: JUN 12, 2025

Verifier E-Sig:/ES/OUTSIDE SERVICE RADIOLOGY

Report

CHEST SINGLE VIEW

CLINICAL HISTORY: dyspnea cough

NUMBER OF IMAGES: 2 (bone suppression)

COMPARISON: No priors available

FINDINGS

Lung volumes are normal.

Retrocardiac opacity is concerning for pneumonia.

No visible effusion or pneumothorax.

The cardiomediastinal silhouette is normal.

Left subclavian approach pacemaker remains in place.

No acute osseous abnormality.

Impression

Retrocardiac opacity is concerning for pneumonia.

READING PHYSICIAN: Charles Rawson, M.D. -1104114651

6/12/2025 18: 54 HAST

VHA National Teleradiology Program

877-780-5559 (For Medical Practitioner Use Only)

Attention Patients / Veterans: If you have questions or concerns

about these test results, please contact your ordering provider

or primary care team.

Primary Diagnostic Code: SIGNIFICANT ABNORMALITY, ATTN NEEDED

Primary Interpreting Staff

OUTSIDE SERVICE RADIOLOGY, Staff Physician

/

EKG: Atrial fibrillation with rapid ventricular response, bifascicular block,

heart rate 117, no acute definitive injury pattern noted per my assessment

MEDICAL DECISION MAKING

Concern for acute hypoxic respiratory failure, ABG at outside facility shows

normal pH with no hypercarbia, patient with COPD exacerbation less likely heart

failure.

Labs being repeated. Will provide Xopenex treatment IVC appears flat will

provide IV fluid bolus. Patient already received Solu-Medrol prior to arrival.

No B-lines on ultrasound, IVC is collapsible, can receive IV fluid.

Will be admitted.

Patient with retrocardiac opacity on chest x-ray, treated for sepsis in setting

of pneumonia, vancomycin and cefepime ordered due to patient being recently

admitted in the hospital.

PHYSICIAN

Emergency Department/Urgent Care Center Triage

Patient age: 78 Birth Sex in chart: MALE

Mode of Arrival

Ambulance

Pre-arrival interventions

transfer from barstow comm ED

Mode of Mobility: *

Stretcher

Chief Complaint

afib, sob

Triage RN Note (Subjective/Objective)

pt biba, xfer from barstow comm ed for afib and sob/copd exacerbation. pt calm

quiet cooperitive, gcs 15 a/ox4, respirations even, shallow, unlabored, non

productive cough, speaking in 2-7 word senctences, 2L o2 via NC “as needed” per

pt, skin warm and dry, mucous membranes moist, no distress, ekg completed,

placed on cardiac monitor, labs drawn and sent per md orders. dr zaidi at

bedside for eval.

Level of Consciousness (AVPU)

Alert = Appears aware of and responsive to the environment on their own.

Follows commands, opens eyes spontaneously, and tracks objects.

Vital Signs

Vital signs previously recorded this visit

VSD – Detailed Vitals

Date Vital Measurement Qualifiers

06/12/2025 20: 50 Temp F (C) 97.9 (36.6)

” ” Pulse 122

” ” Respir 22

” ” BP 111/66

” ” Pain 0

” ” POx (L/Min)(%) 96 (2)() Nasal Cannula

05/22/2025 14: 44 Wt lbs (kg)[BMI] 214.9 (97.48)[30*]

07/11/2019 13: 53 Ht in (cm) 71 (180.34)

National Early Warning Score (NEWS)

The NEWS total is 6.

• Temperature (C/F):

Score = 0 36.1 – 38.0 C (96.9 – 100.4 F)

• Pulse:

Score = 2 111-130

• Respirations:

Score = 2 21-24

• Blood Pressure (Only Systolic BP, mmHg):

Score = 0 111-219

• Pulse Oximetry:

Score = 0 96% or greater

• Supplemental oxygen in use:

Score = 2 Yes

• AVPU:

Score = 0 Alert

Pain

No pain

Pain Score: 0

Suicide Screen

Columbia Suicide Severity Rating Scale (C-SSRS) screener

• Over the past month, have you wished you were dead or wished you could go

to sleep and not wake up?

No

• Over the past month, have you had any actual thoughts of killing yourself?

No

• Over the past month, have you been thinking about how you might do this?

Response not required due to responses to other questions.

• Over the past month, have you had these thoughts and had some intention of

acting on them?

Response not required due to responses to other questions.

• Over the past month, have you started to work out or worked out the

details of how to kill yourself?

Response not required due to responses to other questions.

• If yes, at any time in the past month did you intend to carry out this

plan?

Response not required due to responses to other questions.

• In your lifetime, have you ever done anything, started to do anything, or

prepared to do anything to end your life (for example, collected pills,

obtained a gun, gave away valuables, went to the roof but didn’t jump)?

No

• If YES, was this within the past 3 months?

Response not required due to responses to other questions.

Emergency Severity Index (ESI) level

Level 2

Fall Risk Screen

Patient is considered a fall risk due to the following

Age greater than 70

Interventions

Fall prevention instructions given

Patient placed in view of staff

Previously documented allergies: Patient has answered NKA

Current Problems

Atrial fibrillation (SCT 49436004)

Chronic obstructive lung disease (SCT 13

Hyperlipidemia (SCT 55822004)

Anxiety (SCT 48694002)

History of alcohol abuse (SCT 371434005)

Allergic rhinitis (SCT 61582004)

Hearing Loss (SCT 15188001)

Tinnitus (SCT 60862001)

Order SWS/EMERGENCY DEPT OUTPT Consult?

No

Reason

–

Gynecological Assessment

Is the patient homeless?

No

Are you on hospice?

NO

Dispo to: bed 19

RN

COMMUNITY CARE-EMER SELF PRESENTING CARE COORD PLAN NOTE Has ADDENDA

Emergency Notification Intake

Date Presenting to the Facility: Jun 12,2025

Method of Contact

Submitted to Centralized Call Center

Notification ID: L-20250612211056832

HSRM Referral #:

Community Hospital Name

Hospital: BARSTOW COMMUNITY HOSPITAL

Address

City: Barstow

State: CA

Zip Code

Phone

Community Facility Point of Contact

Name

Phone

Chief complaint: FOUND UNCONSCIOUS

Primary Diagnosis

Disposition

PER OPERATOR PATIENT REMAINS IN THE ED. WILL UPDATE NOTE UPON FURTHER CONTACT.

Healthcare Technician

STAFF NURSE

STAFF NURSE

STAFF NURSE

Called (760) 256-0845 asked for Lee, David for follow up the person who

answered the phone stated: patient Mr. Lee is currently being transported by

ambulance right now, he is not doing well & ended the call.

Phone appointment rescheduled.

Specialty Clinics RN

LOCAL TITLE: CCC: CLINICAL TRIAGE

STANDARD TITLE: RN PROGRESS NOTE