[Daily] 021318

T. UTI with levaquin for suppression
=> MEROPENEM for covering for now!!!
=> ID call.

Pyelo - images in 3 days if it's not improving,
Most patients with acute complicated UTI do not warrant imaging studies for diagnosis or management. Imaging is generally reserved for those who are severely ill, have persistent clinical symptoms despite 48 to 72 hours of appropriate antimicrobial therapy, or have suspected urinary tract obstruction (eg, if the renal function has declined below baseline or if there is a precipitous decline in the urinary output). Imaging is also appropriate in patients who have recurrent symptoms within a few weeks of treatment


T.

• A burning feeling when you urinate
• A frequent or intense urge to urinate, even though little comes out when you do
• Pain or pressure in your back or lower abdomen
• Cloudy, dark, bloody, or strange-smelling urine
• Feeling tired or shaky
• Fever or chills (a sign the infection may have reached your kidneys)
• = even with systemic symptom! 

T.

ASSESSMENT/PLAN/RECOMMENDATIONS:

Pt with heart transplant with CAV c/b multiorgan injury including kidney and liver.  Likely cardiogenic hepatopathy, unclear if cirrhotic as well.
Large ascites of unclear etiology with slow response to diruesis.

#. Abdominal Ascites in context of some elevated R-sided pressure (TTE 6/2017) and mild Tricuspid regurg
- pt currently on Lasix 40 and Spironalactone 100; it is difficult to comment on how best to adjust diuretics without first knowing the etiology of the ascites
- agree with procedure team consult to repeat large-volume paracentesis;  must also send hepatic function panel tomorrow (to get albumin level), and also send ascites fluid labs including ascites albumin and ascites total protein.
- if SAAG >1.1 and Tprot >2.5, suggest ascites is from cardiogenic source
- if SAAG >1.1 and Tprot <2.5, suggest there may be hepatic-induced portal hypertension and so a followup transhepatic pressure gradient and liver biopsy (IR procedures) would be warranted.
- obtain urine lytes; urine Na, urine K, urine Cr (on current diuretic therapy); this can assist in adjustment of diuretics
- recommend also obtaining Renal consult now; he has not been seen by them since 6/2017 though patient is listed for kidney transplant; they can also assist in diuretic adjustment based on renal function. If pt renal function limited, oral diuretic regimen may be difficult.

Please page GI fellow on call with any questions or change in clinical status.
Patient seen and discussed but not seen with, Dr. Sterling. Patient will be formerly staffed tomorrow by Hepatology team.