Approach to hyperthyroidism and thyrotoxicosis Quiz: Ace Your Exams

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A 56-year-old woman is brought to the emergency department by her son for evaluation of unusual behavior. Her son states that she has been short-tempered and hears voices that others do not hear. The patient states she has been feeling her heart racing for one week and has had difficulty writing due to tremulous hands. She is nauseous and has had diarrhea for two days. Three weeks ago she took a home test and was positive for COVID-19. She has a history of hypertension treated with amlodipine but has not seen a doctor in over two years.  Temperature is 37.7°C (99.8°F), pulse is 152/min, respiratory rate is 22/min, and blood pressure is 181/102 mmHg. The patient appears agitated and is pacing around the exam room.  She appears distracted by auditory hallucinations. A nontender goiter is palpated over the anterior neck. A fine tremor of the hands is observed. ECG shows atrial fibrillation with rapid ventricular response. Laboratory results are shown below. Which of the following is the best next step in management?

 Laboratory value  Result  Reference range
 TSH  0.02 mIU/L  0.5-5 mIU/L 
 Serum free T4  20.1 ng/dL  0.9-2.3 ng/dL

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