Family Medicine Board Review Sample Questions

The correct answer is E. Cultures, empiric antibiotics including coverage for disseminated candidiasis, supplemental oxygen, maintain blood pressure, and consider dobutamine

Explanation: This patient has a mean arterial pressure of 70 mmHg and is breathing on his own. It is reasonable to add supplemental oxygen, and empiric antibiotics should be started immediately after obtaining clinically appropriate cultures. Because this patient has evidence of candida, disseminated candidiasis should be considered a potential source of infection. Surviving Sepsis guidelines indicate that cultures should be done before antimicrobial therapy if there is no significant delay before the start of therapy.

With respect to the other therapies, mechanical ventilation is not indicated at this time. Central venous pressure monitoring will be useful to determine if the patient has high filling pressures that may indicate a need for a cardiac inotrope. Renal-dose dopamine is not recommended. Intensive insulin therapy is not recommended except in patients with a blood glucose level >180mg/dL. Platelet transfusions are not indicated unless the platelet count is <10,000/mm3, <20,000/mm^3 in patients at risk for bleeding, or at 50,000/mm3 in patients who are actively bleeding or undergoing surgery or an invasive procedure. Routine red blood cell transfusions are not recommended in sepsis for hemoglobin above 7g/dL.