 Welcome back to our MedSmarter question of the week where we're taking a smarter approach to preparing future physicians. Before we get started, if you'll take just a quick minute and click that like button and also subscribe and turn the bell on so that you'll be notified when we post new videos. Let's get right to that question. And as always, we start with the last sentence of the vignette and go back and read the rest. Following primary stabilization, which of the following would constitute appropriate pharmacotherapy for this patient's underlying condition? An unresponsive 35 year old female with a history of Graves disease is brought to the emergency department following a bout of confusion and agitation. On physical exam, her temperature is 39.4 degrees Celsius or 102.9. Her blood pressure is 104 over 72 and her pulse is 160 per minute. A systolic ejection murmur is heard at the apex of the heart and the patient has three plus putting endema at the ankles. So following primary stabilization, which of the following would constitute appropriate pharmacotherapy for this patient's underlying condition? So the first thing to note here is that they're not asking the first steps. The primary stabilization is that first steps. What are the primary stabilization? Airway breathing circulation, your ABCs. So they've already checked airway breathing circulation because we do see that this is an unresponsive 35 year old female. So that unresponsive is something that needs to be addressed right from the bat. So let's go back and let's look through this and pay attention to some of the things we need to really focus on. So the unresponsive 35 year old Graves disease, history of Graves disease and they've had confusion and agitation. Looking at their laboratory or their physical findings, we got the 102.9 degree fever or 39.4 Celsius. Blood pressure is low, pulse is high. So we've got a high pulse tachycardic with a low blood pressure and we do have a systolic ejection murmur at the apex and three plus putting endema. So what are we looking for here? Take a minute, read these answer choices, come up with an answer and put your answer in the comment box below. All right, so we have a patient that presents to us with what is a medical emergency. Unresponsive, you see they have a history of Graves disease and we are talking about something that looks like it has something that might have to do with the thyroid. All right, Graves disease here associated with some high temperature, tachycardic and pitting edema, all those kind of things kind of leave me to believe that we're dealing with a form of thyrotoxicosis. And specifically in this one, it's a pretty extreme form of thyrotoxicosis. So what we're seeing is what I believe is a thyroid storm. So what I need to know now is what do I do to help address the underlying situation or the thyroid storm that's going on with this patient? So let's look at these answer choices. A iodine, iodine can exacerbate this situation by stimulating the endogenous synthesis of thyroxine. B dobutamine, dobutamine doesn't work here for me because this would make it worse by exacerbating the adrenergic effects here. So this is going to be something that would cause negative problems on the heart. Something we would want to use is something that's kind of the opposite. We don't want a beta agonist, we would want a beta antagonist. So dobutamine is working in the opposite direction of what I want. C aspirin, if you know much about aspirin, you know that aspirin actually will displace thyroxine from the thyroid binding globule, which is the protein that binds to the thyroxine. So we're actually going to be releasing more thyroxine out into the body that can be active and useful. So that's going to make it worse. So aspirin can cause that to become worse. D, propythyl urocyl, PTU. That actually seems like it might be one. I know we use that in thyroid storm situations. So let's keep that one on and just double check our last one to see if it would fit or not. E levothyroxine, levothyroxine is a treatment for low thyroid. We're having high thyroid, okay? So we're not going to use something that's going to do that with thyrotoxicosis. This is contraindicated in thyrotoxicosis. So that means I'm marking that out, which leaves D as my final answer. And D is the correct answer. So like we said, what we're dealing with here is a thyroid storm, which is an extreme form of thyrotoxicosis. So what we're seeing of these symptoms is beta-adrenergic outflow. So we're getting that high pulse rate. We're getting that little murmur coming in, pitting edema, high temperature. All of those are due to that thyroid storm. So we do our primary stabilization, like we mentioned, for that unresponsive patient. Make sure the airway breathing circulation is okay. And then we're going to use either propythyl urocyl, PTU, or methamazole. So you might also see this as methamazole as your possible answer choice here. And either one of those would be correct. If you found this material helpful for your studying, please like and consider subscribing to the channel. Also, share this video so that more people can benefit from it like you have.