Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 15, 2023 20:54 EST   Verified By: MD on February 15, 2023 20:54 EST   Encounter Info: Hospital, Inpatient, 02/15/23 -     * Final Report *          History of Present Illness/Subjective     Patient is an 80-year-old male with a past history significant for Alzheimer's type dementia, type 2 diabetes mellitus, atrial fibrillation, hypertension presented emergency room after being found hypoxic at the nursing home.  Patient able to give history.  Nursing home found patient weakened and obtunded at the nursing home.  His oxygen saturation was found to be 70% on room air.  For the past 24 hours he had not been eating or drinking well which is much worse than baseline.  As there has been a noted decline and hypoxia he was brought to the emergency room for further evaluation.  He had no noted fevers or chills.  No vomiting or diarrhea noted as well.   In the emergency room his blood pressure was 85/67 pulse rate 107 respiratory rate 23 temperature 36.8 oxygen saturation was 91% on 15 L nonrebreather mask.   Serology: White count 21,600 with left shift hemoglobin 14.4 hematocrit 46.6 and a platelet count of 508,000.  Sodium 152 potassium 3.9 chloride of 113 bicarb 28 BUN 65 creatinine 2.13.  Blood sugar 335.  Calcium 11 alkaline phosphatase 142 ALT 73 AST 29 total bilirubin 0.7 total protein 9.2 albumin 3.8 lipase 22 troponin 43 BNP 85 serum lactate 4.6.  Venous blood gas pH 7.31 PCO2 55 PO2 35.  Urinalysis regarding 1.015 with a pH of 8.5 protein greater than 300.  Large hemoglobin.  Positive nitrite.  Large leukocyte esterase and greater than 100 WBCs as well as greater than 100 RBCs with many bacteria.  COVID PCR positive.  Influenza AMB negative.  CT scan of brain showed negative findings for acute intracranial hemorrhage with no convincing mass effect.  Encephalomalacia in the bilateral cerebral hemispheres as discussed likely representing chronic infarcts.  Advanced generalized volume loss.  Chest x-ray showed left lower lobe airspace disease suspicious for consolidative pneumonia.  Small left pleural effusion.  CTA of the chest showed multifocal pneumonia including dense consolidation left lower lobe.   Past medical history: Progressive dementia, type 2 diabetes mellitus, atrial fibrillation, hypertension, BPH, GERD  Review of Systems     Unable to obtain due to patient being obtunded  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.2 (37.2-38.4)  Temp (FAHR) 99.0 (99.0-101.1), BP 127/54 (92-136)/(49-80), HR 98 (91-131), RR 16 (16-28), O2Sat 94 (87-94) Neurologic (most recent and range for last 24 hours)  GCS 4(4-4)     Patient Weight  Current Daily Weight:    78.9 kg    02/15/23  BMI:    28    02/15/23    Overweight (BMI 25-29.9) Patient Height  Current Height:    168 cm    02/15/23             General: Sedate with mild respiratory distress       Eye:  Extraocular movements are intact       HEENT:  Normocephalic       Neck:  Supple, Non-tender normal jugular venous pressure       Respiratory: Bibasilar crackles left greater than right with scattered wheezes, fair air exchange, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.        Cardiovascular: Tachycardic rate, irregularly irregular rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, No edema.          Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds, no evidence of hepatosplenomegaly.       Lymphatics:  No lymphadenopathy neck       Musculoskeletal:  Normal range of motion, generalized weakness       Integumentary:  Warm, Dry, No rash.         Feet:  Normal by visual exam, Normal pulses,        Neurologic: Sedate yet moving all 4 extremities       Psychiatric: Uncooperative.      Assessment/Plan       1. Sepsis   A41.9  Patient presents with sepsis criteria source likely being that of pneumonia/COVID/UTI.  Sepsis protocol has been initiated.  Patient's been given IV fluid rehydration.  Blood cultures x2 including urine for Legionella and strep antigens are pending.  Patient has been started on broad-spectrum IV antibiotic therapy will make adjustments antibiotics based on culture data.  Procalcitonin level pending as well.   2. Pneumonia   J18.9  Institutional acquired pneumonia.  Broad-spectrum antibiotics have been started.  Culture data pending.  Continue RT protocol and oxygen titration to maintain saturations greater than 88%.   3. COVID-19   U07.1  Patient presents with COVID-19.  His symptoms all appear to be very aggressive with a short timeframe within the last 48 hours.  Given this to be placed in appropriate isolation protocol.  Inflammatory markers have been sent.  Culture data pending and treatment for secondary bacterial infections underway.  He will be started on remdesivir day 1/5 and dexamethasone day 1/10 as well as continue supportive care.  Continue to monitor hydration status very closely as not to produce fluid overload that may lead and put him at risk for ARDS.   4. Hypernatremia   E87.0  Patient has hypovolemic hypernatremia.  Again secondary to dehydration.  We will continue judicious IV fluid rehydration and monitor sodium levels closely making adjustments in fluid type and rate accordingly.   5. Acute kidney injury   N17.9  Patient is acute kidney injury secondary likely to prerenal azotemia and/or associated with his UTI.  We will continue IV fluid rehydration with close monitoring of renal function and treatment of underlying infection.   6. Acute respiratory failure   J96.00  Patient presents for acute respiratory failure.  Currently on high flow oxygen therapy.  He is DNR/DNI comprehensive care.  We will not be intubating this patient according to his wishes if he progresses would consider BiPAP therapy.  Continue RT protocol and treatment of underlying infection.   7. UTI symptoms   R39.9  Patient presents with a UTI.  Urine culture pending.  Broad-spectrum antibiotic coverage has been started.  We will follow-up on culture data and make adjustments antibiotics accordingly.   8. Dementia   F03.90  Patient has baseline dementia and fairly end-stage.  Once tolerating p.o. we will titrate in his home regimen.   9. Type 2 diabetes mellitus   E11.9  Patient blood sugars were significantly elevated on presentation.  We will start on insulin therapy.  We will continue to monitor in the presence of Decadron therapy and will titrate insulin treatments accordingly.  Continue sliding scale insulin as well.   10. Atrial fibrillation   I48.91  Continue monitor closely.  We will initiate rate lowering agents as blood pressure allows.  May require digoxin but will have to monitor closely with renal insufficiency.  We will start anticoagulation as well and continue close monitoring in the ICU setting.   11. Hypertension   I10  Patient is time is hypotensive and septic.  All antihypertensive agents to be on hold for now we will titrate and accordingly.   12. GERD (gastroesophageal reflux disease)   K21.9  Continue reflux precautions and IV PPI therapy.   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/15/23 11:43:00 EST  acetaminophen, 1,000 mg, Orally, Tablet, Q8H, PRN, Pain Mild PO (1-3 out of 10), 02/15/23 11:43:00 EST  dexamethasone, 6 mg, IV Push, Injection, Daily, 02/15/23 12:00:00 EST, for 10 Doses, 02/24/23 9:00:00 EST  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 02/15/23 11:43:00 EST, PRN - See Comments, Clinical Weight  doxycycline, 100 mg, IVPB, Injection, Q12, Indication: Pneumonia - Tailored based on cultures, 02/15/23 12:00:00 EST, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  enoxaparin, 40 mg, Subcutaneous, Injection, At Bedtime, Routine, 02/15/23 21:00:00 EST  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 02/15/23 11:43:00 EST  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 02/15/23 11:43:00 EST  insulin glargine, 15 Units, Subcutaneous, Injection, At Bedtime, 02/15/23 21:00:00 EST  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 02/15/23 11:43:00 EST  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/15/23 11:43:00 EST, 130 mL/hr, Clinical Weight  NORepinephrine 8 mg + Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 02/15/23 12:11:00 EST, Titrate - See Comments  pantoprazole, 40 mg, IV Push, Injection, Daily, 02/15/23 13:00:00 EST  piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 02/15/23 12:00:00 EST, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  remdesivir, 100 mg, IVPB, Injection, At Bedtime, 02/16/23 21:00:00 EST, for 4 Doses, 02/19/23 21:00:00 EST, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250  180 gm Carb per day Diet  Admit to Inpatient   Aspiration Precautions  Basic Metabolic Panel  Call (Specify)  Call Blood Glucose  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  Candida auris DNA PCR  CBC w/Differential  CK SerPl QN  CK SerPl QN  Comp Metabolic Panel  CRP SerPl QN  CRP SerPl QN  D-Dimer Pl QN  D-Dimer Pl QN  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Ferritin SerPl QN  Fibrinogen  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Lactate Pl Venous QN  Lactate Pl Venous QN  Lactate Pl Venous QN  LDH SerPl QN  Level of Care  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  MRSA PCR  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  Patient Isolation  Peripheral IV Insertion  Peripheral IV Insertion  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  T4 Free Direct SerPl QN  Titrate FiO2 to Keep O2 Sat  TSH w FreeT4 reflex  Vital Signs  Vital Signs  Weight  Total critical care time: Approximately 50 minutes?sepsis/pneumonia/UTI/acute respiratory failure/COVID-19 infection/hypernatremia  Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.  This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.  Code Status   Resuscitation Status - Ordered    -- 02/15/23 11:43:00 EST, DNR/DNI/Comprehensive Care   Chronic Problem List    Acute kidney injury  Acute respiratory failure  Atrial fibrillation  COVID-19  Dementia  GERD (gastroesophageal reflux disease)  Hypernatremia  Hypertension  Pneumonia  Sepsis  Type 2 diabetes mellitus  UTI symptoms       Medications   Home Medications (22) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  bisacodyl 10 mg rectal suppository 10 mg = 1 Suppository, PRN, Rectally, Q24H  cholecalciferol (vitamin D3) 50 mCg (2,000 intl units) oral tablet 50 mCg = 1 Tablet, Orally, Daily, for two weeks, started 02/02/2023  docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  donepezil 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  Eliquis 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  gabapentin 600 mg oral tablet 600 mg = 1 Tablet, Orally, TID  Glucagon Emergency Kit for Low Blood Sugar 1 mg injection 1 mg, PRN, IM, Unscheduled  glucose 40% oral gel 1 Vial, PRN, Orally, Unscheduled, as needed for blood sugar less than 40mg/dl  loratadine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  lysine 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID, for two weeks, started 02/02/2023  memantine 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID  Milk of Magnesia 8% oral suspension 2.4 GM = 30 mL, Orally, QPM  NovoLOG (insulin aspart) 100 units/mL subcutaneous solution See Instructions, Use to inject per sliding scale subcutaneously before meals,50-199: 2 units 200-299: 6 units300-349: 8 units350-400: 10 units 400-600: 12 call the NP or MD and notify immediately  PARoxetine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  ReliOn/NovOLIN N (insulin NPH) 100 units/mL subcutaneous injection 10 Units, Subcutaneous, Daily  Senna-Time 8.6 mg oral tablet 8.6 mg = 1 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, QPM  Vitamin C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, BID, for two weeks, start date 02/02/2023  Zinc 50 mg, Orally, Daily, for two weeks, started 02/02/2023  zinc oxide 13% topical cream 1 App, Topical, BID, to coccyx  Active Scheduled Inpatient Medications  dexamethasone, Injection, 6 mg, IV Push, Daily, Start: 02/15/23 12:00:00  doxycycline, Injection, 100 mg, IVPB, Q12, Indication: Pneumonia - Tailored based on cultures, Start: 02/15/23 12:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, At Bedtime, Start: 02/15/23 21:00:00  insulin glargine (Lantus (insulin glargine) 100 units/mL subcutaneous solution), Injection, 15 Units, Subcutaneous, At Bedtime, Start: 02/15/23 21:00:00  pantoprazole, Injection, 40 mg, IV Push, Daily, Start: 02/15/23 13:00:00  piperacillin-tazobactam, Injection, 3.375 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/15/23 12:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 02/16/23 21:00:00  Lactated Ringers  1,000 mL IV  130 mL/hr 0  02/15/23  Dextrose 10% in Water  500 mL IV  PRN - See Comments     NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments       One-Time Medications Given 02/14/23 00:00:00 TO 02/15/23 20:54:10  remdesivir, Injection, 200 mg, IVPB, ONCE, (1 DOSE 02/15/23 13:52:00)  PRN Medications (0600 - 0559) from 02/14 - 02/15  acetaminophen, 1,000 mg, Orally, Q8H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 15.9 k/cumm High (02/15/23 05:08:00)  RBC: 4.32 million/cumm (02/15/23 05:08:00)  Hgb: 11.9 GM/dL Low (02/15/23 05:08:00)  Hct: 37.7 % Low (02/15/23 05:08:00)  MCV: 87 fL (02/15/23 05:08:00)  MCH: 27.4 pg (02/15/23 05:08:00)  MCHC: 31.5 GM/dL Low (02/15/23 05:08:00)  RDW: 18.8 % High (02/15/23 05:08:00)  Platelet: 372 k/cumm (02/15/23 05:08:00)  MPV: 9.2 fL (02/15/23 05:08:00)  # WBC Counted in Diff: 100 (02/15/23 05:08:00)  Band: 21 % (02/15/23 05:08:00)  Neutrophil: 58 % (02/15/23 05:08:00)  Lymphocyte: 14 % (02/15/23 05:08:00)  Monocyte: 7 % (02/15/23 05:08:00)  Absolute Band: 3.3 k/cumm High (02/15/23 05:08:00)  Absolute Neutrophil: 9.2 k/cumm High (02/15/23 05:08:00)  Abs Lymphocyte: 2.2 k/cumm (02/15/23 05:08:00)  Absolute Monocyte: 1.1 k/cumm (02/15/23 05:08:00)  RBC Morphology: Normal, (02/15/23 05:08:00)  Platelet Estimate: Adequate. (02/15/23 05:08:00)  Platelet Morphology: Normal, (02/15/23 05:08:00)  Chemistry:  Sodium SerPl QN: 156 mmol/L High (02/15/23 19:03:00)  Potassium SerPl QN: 3.5 mmol/L (02/15/23 19:03:00)  Chloride SerPl QN: 122 mmol/L High (02/15/23 19:03:00)  Carbon Dioxide SerPl QN: 25 mmol/L (02/15/23 19:03:00)  Anion Gap: 9 mmol/L (02/15/23 19:03:00)  BUN SerPl QN: 51 mg/dL High (02/15/23 19:03:00)  Creatinine SerPl QN: 1.55 mg/dL High (02/15/23 19:03:00)  Estimated GFR (CKD-EPI, no race): 45 mL/min/1.73m2 Low (02/15/23 19:03:00)  Estimated CRCL (CG): 38 mL/min Low (02/15/23 19:03:00)  Glucose SerPl QN: 296 mg/dL High (02/15/23 19:03:00)  Calcium Total SerPl QN: 9 mg/dL (02/15/23 19:03:00)  Alkaline Phos SerPl QN: 91 Units/L (02/15/23 05:08:00)  ALT SerPl QN: 43 Units/L (02/15/23 05:08:00)  AST SerPl QN: 20 Units/L (02/15/23 05:08:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (02/14/23 21:36:00)  Bilirubin Total SerPl QN: 1 mg/dL (02/15/23 05:08:00)  Total Protein SerPl QN: 6.1 GM/dL Low (02/15/23 05:08:00)  Albumin SerPl QN: 2.5 GM/dL Low (02/15/23 05:08:00)  Lipase SerPl QN: 22 Units/L (02/14/23 21:36:00)  CK SerPl QN: 456 Units/L High (02/15/23 12:34:00)  Troponin-I High Sensitivity: 43 ng/L High (02/14/23 21:36:00)  BNP Pl QN: 85 pg/mL (02/14/23 21:36:00)  Hemoglobin A1C HPLC Bld QN: 7.8 % High (02/15/23 12:34:00)  Est Average Glucose mg/dL: 177 mg/dL High (02/15/23 12:34:00)  Est Average Glucose mmol/L: 9.81 mmol/L High (02/15/23 12:34:00)  Lactate Venous Pl QN: 3.7 mmol/L High (02/15/23 19:03:00)  Gluc-Strip, POC: 291 mg/dL High (02/15/23 16:36:00)  pH Bld Venous QN: 7.31 Low (02/14/23 21:36:00)  PCO2 Bld Venous QN: 55 mmHg (02/14/23 21:36:00)  PO2 Bld Venous QN: 35 mmHg (02/14/23 21:36:00)  Base Excess Bld Venous: 0 mmol/L (02/14/23 21:36:00)  Bicarb Bld Venous Calc: 28 mmol/L (02/14/23 21:36:00)  O2 Sat Bld Venous Calc: 61 % (02/14/23 21:36:00)  Patient Temperature: 37 DegC (02/14/23 21:36:00)  TSH 3rd Gen SerPl QN: 0.18 mcU/mL Low (02/15/23 12:34:00)  T4 Free Direct SerPl QN: 1.3 ng/dL (02/15/23 12:34:00)  C-Reactive Prot SerPl QN: 28.5 mg/dL High (02/15/23 12:34:00)  Coagulation:  D-Dimer Pl QN: 552 ng/mL DDU High (02/15/23 12:34:00)  Urine Studies:  Color: Brown (02/14/23 22:04:00)  Clarity: Cloudy (02/14/23 22:04:00)  Specific Gravity: 1.015 (02/14/23 22:04:00)  pH: 8.5 (02/14/23 22:04:00)  Protein: >=300 Abnormal (02/14/23 22:04:00)  Glucose: NEGATIVE (02/14/23 22:04:00)  Ketones: 15 Abnormal (02/14/23 22:04:00)  Bilirubin: SC MOD Abnormal (02/14/23 22:04:00)  Hgb Ur: LARGE. Abnormal (02/14/23 22:04:00)  Nitrite: POSITIVE Abnormal (02/14/23 22:04:00)  Urobilinogen: 1.0. (02/14/23 22:04:00)  Leukocyte Esterase Ur: LARGE. Abnormal (02/14/23 22:04:00)  WBC: >100 Abnormal (02/14/23 22:04:00)  RBC: >100 Abnormal (02/14/23 22:04:00)  Bacteria: Many Abnormal (02/14/23 22:04:00)  Squamous Epithelial: NONE (02/14/23 22:04:00)  Renal Epithelial: Few Abnormal (02/14/23 22:04:00)  Transitional Epithelial: Few (02/14/23 22:04:00)  Mucous: PRESENT. (02/14/23 22:04:00)  All Other Labs:  Procalcitonin: 3.37 ng/mL (02/15/23 12:34:00)  MRSA PCR: GeneXpert 46 (02/15/23 12:34:00)  Staph aureus PCR: GeneXpert 46 (02/15/23 12:34:00)  COVID 19 Specimen Source: Nasal (02/14/23 21:46:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/14/23 21:46:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/14/23 21:46:00)  Rapid Influenza A PCR: Not Detected (02/14/23 21:46:00)  Rapid Influenza B PCR: Not Detected (02/14/23 21:46:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/14/2023 20:58 - XR Chest PA or AP Portable  IMPRESSION:1.  Left lower lobe airspace disease suspicious for consolidativepneumonia. Correlate clinically for signs and symptoms of pulmonaryinfection.2.  Small left pleural effusion.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/14/2023 23:34 - CT Head W/o IV Contrast  IMPRESSION:  1.  Negative for acute intracranial hemorrhage. No convincing masseffect.2.  Encephalomalacia in the bilateral cerebral hemispheres asdiscussed. These likely reflect chronic infarcts.3.  Advanced generalized volume loss.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/14/2023 23:35 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Multifocal pneumonia, including dense consolidation left lowerlobe. Recommend follow-up to resolution to exclude any underlyinglesions.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/15/23 20:54 EST ________________________________________________________ MD