A 58-year-old woman is brought to the emergency department due to a 1-day history of fever… — USMLE Step 2 CK

A 58-year-old woman is brought to the emergency department due to a 1-day history of fever, chills, and progressive shortness of breath. She completed her second cycle of systemic chemotherapy (docetaxel and cyclophosphamide) for node-positive breast cancer 8 days ago. Medical history is significant for ischemic cardiomyopathy (left ventricular ejection fraction 40%) and moderate chronic obstructive pulmonary disease. Her temperature is 38.9°C (102.0°F), blood pressure is 84/54 mm Hg, pulse is 118/min, and respirations are 24/min. Pulse oximetry shows 91% on room air. The patient appears lethargic. Jugular venous pressure is 6 cm H2O. Lung auscultation reveals crackles in the right lower lung base. Heart sounds are rapid but regular, with no S3 gallop. The extremities are warm to the touch. Laboratory results are as follows:

Hemoglobin: 9.8 g/dL
Leukocyte count: $600/\mu L$
Absolute neutrophil count: $120/\mu L$
Platelet count: $110,000/\mu L$
Creatinine: 1.4 mg/dL
Thyroid-stimulating hormone (TSH): $0.4\ \mu U/mL$
Free T4: $0.9\ ng/dL$

Which of the following is the most appropriate next step in the management of this patient?

Obtain blood cultures and administer intravenous cefepimeCevap
B
Administer intravenous furosemide and noninvasive positive pressure ventilation
C
Administer oral azithromycin and discharge with close outpatient follow-up
D
Transport the patient immediately for a CT pulmonary angiography
E
Administer intravenous levothyroxine and hydrocortisone

Cevap

Obtain blood cultures and administer intravenous cefepime

The correct action is to obtain blood cultures and administer intravenous cefepime. This patient has febrile neutropenia (defined as a temperature > 38.3°C and an absolute neutrophil count < 500/μL), which is a life-threatening oncologic emergency. Her hypotension (84/54 mm Hg) and warm extremities strongly suggest distributive shock secondary to sepsis, likely from a pulmonary source given the right lower lobe crackles. In high-risk patients (e.g., those with hemodynamic instability or profound neutropenia), blood cultures must be drawn and empiric intravenous broad-spectrum antibiotics with anti-pseudomonal activity (such as cefepime, meropenem, or piperacillin-tazobactam) must be initiated immediately to prevent rapid clinical deterioration and death.

Adım Adım Çözüm

Calculate Absolute Neutrophil Count (ANC) and evaluate vital signs.

ANC is 120/μL (< 500/μL) and patient is hypotensive with fever.

Identifies the clinical syndrome as high-risk febrile neutropenia with septic shock.

Differentiate the etiology of shock based on physical exam findings.

Warm extremities, normal JVP, and lack of an S3 gallop indicate distributive (septic) shock rather than cardiogenic shock.

Prevents inappropriate administration of diuretics which would worsen hypotension.

Determine the required initial therapeutic intervention.

Immediate blood cultures followed by an anti-pseudomonal beta-lactam (cefepime).

Febrile neutropenia is an oncologic emergency requiring emergent empiric broad-spectrum antibiotic therapy.

Anahtar Kavram

High-risk febrile neutropenia presenting with septic shock requires immediate empiric broad-spectrum intravenous antibiotics with anti-pseudomonal coverage.

Soru

Cevap

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