A 36-year-old woman presents with fever, delirium, atrial fibrillation at 160 per minute, and a diffusely enlarged tender-free goitre. Free T4 is markedly elevated. Which sequence of therapy is most appropriate?
- A Propranolol first, followed by propylthiouracil, then iodine one hour later ✓
- B Iodine first, followed by carbimazole, then propranolol
- C Propylthiouracil first, followed immediately by iodine, with propranolol withheld until euthyroid
- D Radioiodine ablation as the definitive first step
Correct answer: A. Propranolol first, followed by propylthiouracil, then iodine one hour later
Explanation
Thyroid storm management follows a fixed order: beta blockade controls adrenergic manifestations, then a thionamide blocks new hormone synthesis, and iodine is given at least one hour afterwards. Giving iodine before the thionamide provides substrate for new hormone synthesis and worsens the storm, so option B is wrong. Radioiodine is contraindicated acutely, and beta blockade should not be delayed. Propylthiouracil is preferred over carbimazole here for its peripheral T4 to T3 conversion block.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.