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Test yourself with a short set of questions on the topic of Neutropenic Sepsis!

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Approach to the patient with Neutropenic Sepsis

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Question 1

Stem 1, question 1 of 4

David, a 64 year old male, presents to GP feeling generally unwell with chills and a fever. David is day 5 post fluorouracil infusion.

Which of the following is NOT a diagnostic criteria for neutropenic sepsis?
A
A decreased urine output
B
A neutrophil count of 0.8 x10 ^9 per litre
C
A temperature higher than 38C
D
Severe breathlessness
E
Tachypnoea
Question 1 Explanation: 
This is a classic style of question testing if you do know the criteria rather than making an educated guess. NICE states "Diagnose neutropenic sepsis in patients having anticancer treatment whose neutrophil count is 0.5 x10^9 per litre or lower and and who have either: 1) a temperature higher than 38C or 2) other signs or symptoms consistent with clinically significant sepsis". Therefore, looking at the answer options the only choice that does not meet this criteria is the neutrophil count answer choice as the criteria states it must be 0.5 x10^9 or less.
Question 2

Stem 1, question 2 of 4

David is admitted to hospital with neutropenic sepsis and a cannula is inserted into his cephalic vein. Which of the following describes the relationship between the cephalic vein and the anatomical snuffbox?
A
The cephalic vein passes below the roof of the anatomical snuffbox from the lateral side of the dorsal venous network
B
The cephalic vein passes over the roof of the anatomical snuffbox from the medial side of the dorsal venous network
C
The cephalic vein crosses the of the anatomical snuffbox from the lateral side of the dorsal venous network
D
The cephalic vein passes under the floor of the anatomical snuffbox from the medial side of the dorsal venous network
E
The cephalic vein crosses the anatomical snuffbox from the lateral side of the dorsal venous network
Question 2 Explanation: 
A clinical application of anatomy here! The cephalic (outdated term Houseman's) vein is often cannulated due to its reliability. The anatomical snuffbox is triangular fossa found at the base of the thumb at the level of the carpal bones, formed by the tendons of extensor pollicis longus, extensor pollicis brevis and adductor pollicis longus. The cephalic vein crosses the anatomical snuffbox from the lateral side of the dorsal venous network. If you are still unsure, TeachMeAnatomy has a good explanation of the anatomical snuffbox.
Question 3

Stem 1, question 3 of 4

David had previously had a fluorouracil infusion, what is the mechanism of action of fluorouracil?
A
DNA crosslinking
B
Inhibition of microtubule assembly in the mitotic spindle
C
Inhibition of dihydrofolate reductase and DNA synthesis
D
Inhibition of RNA and DNA synthesis
E
Targeting of cells over expressing Human Epidermal Growth Factor Receptor-2 (HER-2)
Question 3 Explanation: 
This question tests your knowledge of anti-neoplastic drugs. Fluorouracil is an antipyrimidine and so inhibits RNA and DNA synthesis and so inhibits the production of cytosine, thymine and uracil. DNA crosslinking is the mechanism of alkylating agents like cyclophosamide. Inhibition of microtubule assembly is the mechanism of taxanes and vinca alkaloids. Antifolates such as methotrexate work by inhibiting dihydrofolate reductase. Targeting HER-2 overexpression is the mechanism of a monoclonal antibody trastuzumab (Herceptin).
Question 4

Stem 1, question 4 of 4

What imaging is appropriate to order in a patient presenting with neutropenic sepsis?
A
CT thorax, abdomen, pelvis
B
Chest radiograph
C
Echocardiogram
D
MRI head
E
Ultrasound of abdomen
Question 4 Explanation: 
Many patients with neutropenic sepsis have pneumonia without a cough or shortness or breath so it is very important to get a chest x-ray to assess for any pneumonia. The other imaging listed may be appropriate to do in specific circumstances but are not first line.
Question 5

Stem 2, question 1 of 4

Priya, a 48 year old female, received her first dose of doxorubicin 4 days ago. She is presenting with fever, cough and malaise.

Priya is diagnosed with neutropenic sepsis and antibiotic therapy is started. What is a loading dose?
A
A small initial dose of a drug given rapidly to achieve therapeutic concentration in the plasma
B
A dose given to achieve steady-state concentration
C
A drug given through the parenteral route to achieve a steady-state concentration
D
A large initial dose of a drug given to rapidly achieve therapeutic concentration in the plasma
E
A large maintenance dose to ensure plasma levels remain within a therapeutic concentration
Question 5 Explanation: 
A loading dose is an initial large dose of a drug (or series of doses) given to rapidly achieve a therapeutic concentration in the body. This technique is often used for drugs with a long half life or if a therapeutic steady state is needed immediately. A loading dose can be given by any route.
Question 6

Stem 2, question 2 of 4

How does chemotherapy produce neutropenia?
A
Destroying megakaryocytes
B
Destroying myeloid progenitor cells
C
Destroying neutrophils directly
D
Destroying lymphoid progenitor cells
E
Destroying pluripotent stem cells only
Question 6 Explanation: 
Chemotherapy produces neutropenia by destroying dividing myeloid progenitor cells, which give rise to neutrophils. Chemotherapy effects are greater in rapidly dividing cells, hence cancerous cells are targeted. In addition to cancerous cells being destroyed, other rapidly dividing cells such as myeloid progenitors and hair cells are destroyed hence neutropenia and hair loss are common side effects with anti-cancer treatments.
Question 7

Stem 2, question 3 of 4

Priya is treated with piperacillin and tazobactam as empirical therapy. Which of the following is a side effect of this class of drug?
A
Anaemia
B
Bradycardia
C
Constipation
D
Fainting
E
Rash
Question 7 Explanation: 
Piperacillin and tazobactam often used as first line for neutropenic sepsis (Please remember to check local antibiotic guidelines for your area!) are are both penicillins so come under the Beta Lactam family. A common side effect of penicillins is that they cause a rash. The other answers listed are side effects of other drugs.
Question 8

Stem 2, question 4 of 4

Priya has her neutropenic sepsis treated, but then develops voluminous diarrhoea and crampy abdominal pain. What is the likely diagnosis?
A
Antibiotic-induced fungal overgrowth
B
New onset colitis
C
Ulcerative colitis
D
Appendicitis
E
Antibiotic-induced Clostridium difficile colitis
Question 8 Explanation: 
The question is getting you to think about the complications of antibiotic therapy rather than looking for another disease process causing a change in bowel habits. Given the recent antibiotic therapy, accompanied by voluminous diarrhoea and crampy abdominal pain, antibiotic induce Closterium difficile colitis is most likely.
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