Sepsis Practice Questions

Question 1

A 70-year-old woman is on hospital day 2 in the medical intensive care unit. She was admitted from the emergency department for a 2-day history of shortness of breath and fever. In the emergency department, her temperature is 39.4°C (103.0°F), the pulse is 120/min, the blood pressure is 94/54 mm Hg, the respiratory rate is 36/min, and oxygen saturation was 82% while on 4L of oxygen via a non-rebreather mask. Chest X-ray shows a right lower lobe consolidation. She was intubated, sedated, and started on broad-spectrum antibiotics for sepsis of pulmonary origin and intravenous norepinephrine for blood pressure support. Since then, her clinical condition has been stable, though her vasopressor and oxygen requirements have not improved. Today, her physician is called to the bedside because her nurse noted some slow bleeding from her intravenous line sites and around her urinary catheter. Which of the following most likely represents the results of coagulation studies for this patient?

Accepted Answer

D-dimer: elevated, fibrinogen level: low, platelet count: low

Answer

D-dimer: negative, fibrinogen level: low, platelet count: low

Answer

D-dimer: elevated, fibrinogen level: normal, platelet count: normal

Answer

D-dimer: negative, fibrinogen level: elevated, platelet count: elevated

Answer

D-dimer: negative, fibrinogen level: normal, platelet count: normal

Question 2

A 45-year-old homeless man is brought to the emergency department by the police. He was found intoxicated and passed out in a library. The patient has a past medical history of IV drug abuse, diabetes, alcohol abuse, and malnutrition. The patient has been hospitalized previously for multiple episodes of pancreatitis and sepsis. Currently, the patient is minimally responsive and only withdraws his extremities in response to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam is notable for tachycardia, a diastolic murmur at the left lower sternal border, and bilateral crackles on pulmonary exam. The patient is started on IV fluids, vancomycin, and piperacillin-tazobactam. Laboratory values are ordered as seen below.

Hemoglobin: 9 g/dL
Hematocrit: 30%
Leukocyte count: 11,500/mm^3 with normal differential
Platelet count: 297,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.0 mEq/L
HCO3-: 28 mEq/L
BUN: 33 mg/dL
Glucose: 60 mg/dL
Creatinine: 1.7 mg/dL
Ca2+: 9.7 mg/dL
PT: 20 seconds
aPTT: 60 seconds
AST: 1,010 U/L
ALT: 950 U/L

The patient is admitted to the medical floor. Five days later, the patient's neurological status has improved. His temperature is 99.5°F (37.5°C), blood pressure is 130/90 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 99% on room air. Laboratory values are repeated as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 32%
Leukocyte count: 9,500/mm^3 with normal differential
Platelet count: 199,000/mm^3

Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 31 mg/dL
Glucose: 100 mg/dL
Creatinine: 1.6 mg/dL
Ca2+: 9.0 mg/dL
PT: 40 seconds
aPTT: 90 seconds
AST: 150 U/L
ALT: 90 U/L

Which of the following is the best description of this patient’s current status?

Accepted Answer

Fulminant liver failure

Answer

Recovery from acute renal failure

Answer

Acute renal failure

Answer

Recovery from ischemic liver disease

Answer

Recovery from acute alcoholic liver disease

Question 3

A 77-year-old woman is brought to the emergency department from her nursing home because she was found down overnight. On presentation she was found to be delirious and was unable to answer questions. Chart review shows that she is allergic to cephalosporins. Her temperature is 102.2°F (39°C), blood pressure is 105/52 mmHg, pulse is 94/min, and respirations are 23/min. Physical exam reveals a productive cough. A metabolic panel is obtained with the following results:

Serum:
Na+: 135 mEq/L
Cl-: 95 mEq/L
K+: 4 mEq/L
HCO3-: 19 mEq/L
BUN: 40 mg/dL
Creatinine: 2.5 mg/dL
Glucose: 150 mg/dL

Based on these findings two different drugs are started empirically. Gram stain on a blood sample is performed showing the presence of gram-positive organisms on all samples. One of the drugs is subsequently stopped. The drug that was most likely stopped has which of the following characteristics?

Accepted Answer

Single-ringed ß-lactam structure

Answer

Resistance conveyed through acetylation

Answer

Associated with red man syndrome

Answer

Causes discolored teeth in children

Answer

Accumulates inside bacteria via O2-dependent uptake

Question 4

A 75-year-old male arrives by ambulance to the emergency room severely confused. His vitals are T 40 C, HR 120 bpm, BP 80/55 mmHg, RR 25. His wife explains that he injured himself about a week ago while cooking, and several days later his finger became infected, oozing with pus. He ignored her warning to see a doctor and even refused after he developed fever, chills, and severe fatigue yesterday. After being seen by the emergency physician, he was given antibiotics and IV fluids. Following initial resuscitation with IV fluids, he remains hypotensive. The ED physicians place a central venous catheter and begin infusing norepinephrine. Which of the following receptors are activated by norepinephrine?

Accepted Answer

Alpha 1, Alpha 2, Beta 1

Answer

Alpha 1, Alpha 2, Beta 1, Beta 2

Answer

Alpha 2

Answer

Alpha 1, Beta 1, Dopamine 1

Answer

Alpha 1, Beta 1

Question 5

A 38-year-old female presents to the emergency room with fevers, fatigue, and anorexia for over a month. Past medical history includes mild mitral valve prolapse. She underwent an uncomplicated tooth extraction approximately 6 weeks ago. Her vital signs include a temperature of 100.8 F, pulse of 83, blood pressure of 110/77, and SpO2 of 97% on room air. On exam, you note a grade III/VI holosystolic murmur at the apex radiating to the axilla as well as several red, painful nodules on her fingers. Which of the following is the next best course of action?

Accepted Answer

Obtain blood cultures x3 sites over 1 hour and start empiric antibiotics

Answer

Blood cultures are not needed. Start empiric antibiotics

Answer

Start anticoagulation with heparin

Answer

Consult cardiothoracic surgery for mitral valve replacement

Answer

Obtain blood cultures x3 sites over 24 hours and start antibiotics after culture results are available

Question 6

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

Accepted Answer

"Can you tell me more about the symptoms you have been experiencing?"

Answer

"Does the diarrhea typically precede the constipation, or vice-versa?"

Answer

"Is the diarrhea foul-smelling?"

Answer

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

Answer

"Are the symptoms worse in the morning or at night?"

Question 7

A 39-year-old man comes to the physician for a follow-up examination. He was treated for a urinary tract infection with trimethoprim-sulfamethoxazole 2 months ago. He is paraplegic as a result of a burst lumbar fracture that occurred after a fall 5 years ago. He has hypertension and type 2 diabetes mellitus. Current medications include enalapril and metformin. He performs clean intermittent catheterization daily. He has smoked one pack of cigarettes daily for 19 years. His temperature is 37.1°C (98.8°F), pulse is 95/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. He appears malnourished. Examination shows palpable pedal pulse. Multiple dilated tortuous veins are present over both lower extremities. There is a 2-cm wound surrounded by partial-thickness loss of skin and a pink wound bed over the right calcaneum. Neurologic examination shows paraparesis. His hemoglobin A1c is 6.5%, and fingerstick blood glucose concentration is 134 mg/dL. Which of the following is most likely to have prevented this patient's wound?

Accepted Answer

Frequent position changes

Answer

Broad-spectrum antibiotic therapy

Answer

Cessation of smoking

Answer

Heparin therapy

Answer

Topical antibiotic therapy

Question 8

A 38-year-old previously healthy woman develops septic shock from necrotizing fasciitis of the lower extremity. Despite three debridements, broad-spectrum antibiotics (vancomycin, meropenem, clindamycin), IVIG, and aggressive critical care support, she develops refractory shock requiring norepinephrine 1.2 mcg/kg/min, vasopressin 0.04 units/min, and epinephrine 0.1 mcg/kg/min. Lactate is 15 mmol/L. Surgical team recommends hemipelvectomy as last option for source control. Family is devastated. ICU team notes SOFA score of 18. Synthesize an approach to management and decision-making.

Accepted Answer

Multidisciplinary meeting with surgery, ICU, palliative care, and family to discuss realistic outcomes, quality of life, and patient values before decision

Answer

Transfer to ECMO center for consideration of VA-ECMO as bridge to hemipelvectomy

Answer

Continue medical management for 24 hours and proceed with hemipelvectomy only if shock improves

Answer

Decline surgery based on futility given SOFA score >15 and initiate comfort care

Answer

Proceed with hemipelvectomy immediately as only chance for survival with informed consent from family

Question 9

A 52-year-old woman with septic shock from intra-abdominal infection undergoes emergency exploratory laparotomy for perforated diverticulitis with fecal peritonitis. Surgery reveals extensive contamination requiring damage control approach. Postoperatively, she requires norepinephrine 0.8 mcg/kg/min plus vasopressin 0.04 units/min, has lactate of 8.5 mmol/L, temperature 35.2°C, INR 2.8, pH 7.18, and base deficit -12. Planned return to OR is in 48 hours. Evaluate the priority interventions to optimize outcome.

Accepted Answer

Aggressive rewarming, correction of coagulopathy, ongoing resuscitation, and source control at planned reoperation

Answer

Immediate return to OR for definitive repair and anastomosis

Answer

Start therapeutic hypothermia and delay reoperation until hemodynamically stable off vasopressors

Answer

Initiate high-dose vasopressors to maintain MAP >75 mmHg and early enteral nutrition

Answer

Administer massive transfusion protocol and emergency re-exploration within 6 hours

Question 10

A 70-year-old man with recently diagnosed small cell lung cancer presents with septic shock from pneumonia. After initial resuscitation, he requires norepinephrine 0.6 mcg/kg/min and has a lactate of 7.8 mmol/L. His SOFA score is 14. The family requests 'everything be done,' but the patient had previously told his oncologist he would not want prolonged intensive care if his cancer prognosis was poor. Staging shows extensive-stage disease. The ICU team debates goals of care. What represents the most ethically appropriate approach to decision-making?

Accepted Answer

Arrange urgent palliative care consultation and family meeting to discuss patient's previously expressed wishes and realistic prognosis

Answer

Continue maximum therapy per family wishes as they are legal decision-makers

Answer

Obtain ethics consultation to overrule family wishes based on futility

Answer

Continue current therapy for 72 hours then reassess based on clinical trajectory

Answer

Transition to comfort care based on poor oncologic prognosis and high SOFA score

Sepsis

Study Resources

Lessons

Questions

Flashcards

Lessons

SIRS and sepsis definitions

Early recognition of sepsis

Initial resuscitation in sepsis

Source identification and control

Empiric antimicrobial therapy

Fluid resuscitation strategies

Vasopressors and inotropic support

Blood culture technique and interpretation

Sepsis-induced organ dysfunction management

Septic shock management

De-escalation strategies

Biomarkers in sepsis management

Sepsis bundles and quality metrics

Practice Questions

Flashcards

About Sepsis for USMLE

Lessons in Sepsis

Master Sepsis