A 72-year-old female resident of an assisted living facility is brought to the emergency d… — USMLE Step 3

A $72$ -year-old female resident of an assisted living facility is brought to the emergency department due to acute confusion and lethargy that has worsened over the past $12$ hours. Staff report that she has had a productive cough and poor appetite for the last three days. Her medical history is significant for type 2 diabetes mellitus, hypertension, and a previous ischemic stroke with mild residual left-sided weakness. Her temperature is $39.4^\circ\text{C}$ ( $102.9^\circ\text{F}$ ), pulse is $132$ /min, blood pressure is $72/40$ mm Hg, and respiratory rate is $26$ /min. Pulse oximetry shows $94\%$ on room air. On physical examination, she is somnolent but arouses to verbal stimuli and appropriately withdraws all four extremities from pain. Her mucous membranes are exceedingly dry, and capillary refill is delayed at $4$ seconds. Lung auscultation reveals coarse crackles in the right lower lobe. Which of the following is the most appropriate initial step in the management of this patient?

Rapid intravenous administration of a balanced crystalloid solutionAnswer
B
Non-contrast computed tomography of the head
C
Obtaining a portable chest radiograph
D
Immediate transfer to the medical intensive care unit
E
Initiation of an intravenous norepinephrine infusion

Answer

Rapid intravenous administration of a balanced crystalloid solution

This patient is presenting with classic signs of septic shock, likely secondary to community-acquired pneumonia (fever, crackles, productive cough). The triad of profound hypotension, tachycardia, and poor peripheral perfusion (delayed capillary refill) indicates life-threatening circulatory failure. In the acute management of septic shock, the absolute first priority is hemodynamic stabilization to restore tissue perfusion. This is achieved by administering rapid, large-volume intravenous crystalloids (typically

30

mL/kg within the first three hours). Once fluid resuscitation is underway, blood cultures should be drawn, broad-spectrum antibiotics administered, and the source of infection investigated. Circulatory stabilization must always take precedence over diagnostic testing.

Step-by-Step Solution

Evaluate the patient's vital signs and clinical presentation.

The patient demonstrates profound hypotension (

72/40

mm Hg), marked tachycardia (

132

/min), high fever, and delayed capillary refill in the setting of a suspected lower respiratory tract infection.

Recognizing the pattern of distributive shock is required to prioritize immediate interventions over secondary diagnostic evaluations.

Determine the highest priority intervention according to acute resuscitation guidelines.

Hemodynamic stabilization via volume expansion is identified as the most urgent need.

In septic shock, restoring intravascular volume with rapid crystalloid administration (

30

mL/kg) is the critical first step in reversing life-threatening hypoperfusion and stabilizing the patient.

Key Concept

In patients presenting with severe sepsis or septic shock, immediate hemodynamic stabilization with rapid intravenous crystalloid fluid resuscitation must take precedence over diagnostic imaging, vasopressor initiation, and disposition changes.

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