2024-25 New Edition Family Medicine Sample Question
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- 1,400+ ABFM-style practice questions
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- 150 all-new questions not included in the SmartBank
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Try This FM Prep Sample Question from the 2024-25 New Edition
A 72-year-old woman presents to the emergency department for fever of 2 days duration. Her family states that she has not had any urine output over the past 12 hours, and that since this morning she has become increasingly somnolent. Her vital signs include: temperature 103 ºF, respirations 22/min, pulse 102/min, blood pressure 102/70 mm Hg, and oxygen saturation 92% on room air. She weighs 72 kg. On examination, she is pale, and somnolent but arousable. She has decreased skin turgor, bibasilar rales, and an ulceration over her sacrum draining purulent material. Blood is sent for laboratory testing and culture, and her wound is cultured. You have already placed a central venous catheter when you observe repeat vitals with regular heart rate of 116/min and blood pressure of 88/52 mm Hg. She has already received 3 L of 0.9% saline as fluid boluses in the past hour.
Which of the following is the best next step in management of this patient?
- Begin maintenance intravenous fluids at a rate of 150 cc/hr
- Debride her sacral decubitus ulcer
- Initiate mechanical ventilation
- Initiate norepinephrine
- Repeat 1 L normal saline intravenous fluid bolus
Show The Answer Key
Did you get it right? The correct answer is D.
Answer Explanation
The patient is exhibiting signs of septic shock—based on systemic inflammatory response syndrome (SIRS) criteria of a suspected skin source of cellulitis related to a sacral decubitus ulcer. Her change in mental status defines organ dysfunction attributable to severe sepsis and she meets criteria for septic shock, given a mean arterial pressure (MAP) of 64 (or less than 65 despite fluid resuscitation of 20–40 cc/kg.) Norepinephrine should be initiated as vasopressor therapy in this patient.
Incorrect Answer Explanations
Answer A: Begin maintenance intravenous (IV) fluids at a rate of 150 cc/hr, is incorrect. Maintenance IV fluids would not be adequate in this hemodynamically unstable patient. She requires vasopressor therapy.
Answer B: Debride her sacral decubitus ulcer, is incorrect. While debridement of the sacral decubitus ulcer will improve wound healing times, she is not currently stable enough to undergo a nonemergent surgical procedure.
Answer C: Initiate mechanical ventilation, is incorrect. Mechanical ventilation is not indicated in this patient. Although she is exhibiting signs of SIRS (fever, tachycardia, and tachypnea), her respiratory status is not currently unstable (i.e., she is maintaining her oxygen saturation above 90%). Supplemental oxygen should be administered via nasal cannula, however, given her sepsis status.
Answer E: Repeat 1 L normal saline IV fluid bolus, is incorrect. While she would benefit from continued hydration with IV fluids, she has already failed a trial of IV fluid resuscitation of more than 20 cc/kg of body weight and will require vasopressor therapy initiation at this time. She also has clinical rales, suggesting that cardiovascular shock is playing a role in her hypotension and that aggressive IV fluid resuscitation may result in fluid overload.
Bottom Line
Vasopressor therapy should be initiated in patients with septic shock who fail IV fluid resuscitation of more than 20–40 cc/kg body weight.
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