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Essential hypertension — USMLE Step 3 MCQ

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HardAmbulatory Medicine / Primary CareEssential hypertensionUSMLE Step 3

A 42-year-old with untreated Graves disease has temperature 40.2°C, atrial fibrillation at 168/min, agitation, vomiting, and heart failure after pneumonia. Propranolol and propylthiouracil are started. Which medication sequence should follow?

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Correct answer: E — Give iodine after propylthiouracil and administer hydrocortisone

The best answer is “Give iodine after propylthiouracil and administer hydrocortisone”. Iodine is administered after a thionamide so it does not provide substrate for new hormone synthesis; glucocorticoid reduces T4-to-T3 conversion and treats possible relative adrenal insufficiency. Radioiodine is too slow, and neither levothyroxine nor cholestyramine alone treats storm. The alternatives are less suitable because they mistime the intervention, omit a necessary component, or apply treatment for a different physiologic problem; the stem's decisive findings determine the sequence.

Reference: American Thyroid Association, Hyperthyroidism and Thyrotoxicosis Guideline: https://www.thyroid.org/thyroidguidelines/file/THY_2010_0417.pdf