"It burns when I pee"



57 year old female with history of recurrent urinary tract infections, hypertension, type II diabetes, depression presents to the emergency department with dizziness and weakness.


Starting two days ago she began having dysuria. She has a history of multiple UTIs and this felt similar. She called her primary care doctor who prescribed levofloxacin however her symptoms continued. Six hours prior to arrival in the ED, she began feeling weak and light headed. She checked her temperature and it was 102, and her husband brought her to the emergency department.


VITALS

T 101.6 HR 120 BP 100/76 RR 22 SPO2 99% on room air


EXAM

General: in mild distress, appears uncomfortable, very thin

CVD: tachycardic, 2/6 systolic murmur

LUNGS: distant breath sounds but some crackles present at bases

ABDOMEN: soft, nontender

EXTREMITIES: no edema or deformity


LABS

WBC 16k

Hgb 11

Plt 200k


BUN 25

Cr 1.3 (baseline 1.0)


Lactate 3.3


Urinalysis: SG 1.01 small blood, TNTC white blood cells, + leukocyte esterase, + nitrates


IMAGING

EKG: sinus tachycardia

CXR: no infiltrates; mild pulmonary edema


POCUS


Cardiac parasternal long


Cardiac apical 4 chamber view


Lung anterior and posterior


Lung R base


IVC longitudinal view



The patient received 2 liters of normal saline on arrival and the ED nurse is hanging another bag now. You are called by the ER physician to admit this patient.


What is the next step in management?


Click for answer and pearls

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