A 68-year-old female with hypertension presented to the emergency department with worsening of lower extremity swelling for the last few months. She appeared to be confused over the last three days according to her husband. He also noted that she had a fever. She had intermittent chest discomfort and was feeling “anxious.” She was compliant with the prescribed antihypertensive (lisinopril and hydrochlorothiazide). She used no tobacco or illicit drug. She had a family history of hypertension and hyperthyroidism.
Her vitals at triage were as follows: BP 170 over 86mmHg, HR 136/min, RR 18/min, Temperature 40.2°C and SP O2 100% on room air. She appeared agitated and flushed, with bilateral exophthalmos and lid lag. Her thyroid was diffusely enlarged with bruit noted. Her pulse was irregularly irregular. She had pitting edema up to the mid-shin. Bilateral plantar reflexes were 3+. The rest of the physical examination was unremarkable.
Her blood test results were as follow:
Normal CBC and renal function.
Calcium: 11.5 mg/dL
Thyroid stimulating hormone (TSH) < 0.01 milli-international unit/L
Free T3: > 30 picogram/mL
Free T4: > 6 nanogram/dL
Pro-BNP: 3,000 picogram/mL
A diagnosis of hyperthyroidism was made, and she was evaluated for possible thyroid storm.