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