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Albuminuric CKD hypertension — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Albuminuric CKD hypertensionUSMLE Step 3

A 39-year-old woman with autoimmune thyroid disease presents with vomiting, abdominal pain, confusion, blood pressure 72/40 mm Hg, sodium 122 mEq/L, potassium 6.2 mEq/L, and glucose 48 mg/dL. Blood can be drawn immediately, but cortisol results will take several hours. Which treatment is most appropriate now?

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Correct answer: D — Give intravenous hydrocortisone with isotonic saline and dextrose after drawing blood

The best answer is “Give intravenous hydrocortisone with isotonic saline and dextrose after drawing blood”. This is adrenal crisis with shock, hyponatremia, hyperkalemia, and hypoglycemia. Cortisol and ACTH may be drawn if that causes no delay, but immediate stress-dose hydrocortisone and volume/glucose resuscitation are lifesaving. Hydrocortisone supplies sufficient acute mineralocorticoid activity; thyroid hormone before glucocorticoid can worsen crisis, and treating potassium alone ignores the cause.

Reference: Endocrine Society Guideline: Primary Adrenal Insufficiency: https://www.endocrine.org/clinical-practice-guidelines/primary-adrenal-insufficiency