Diagnose It Answer — April 26, 2026

34-year-old female presents with extreme agitation, palpitations, profuse sweating, and confusion. Her roommate states she has been 'out of her mind' for the past 6 hours — pacing, unable to sit still, talking incoherently. She has also vomited twice and had loose stools. The roommate states she ran out of 'some endocrine medication' about 2 weeks ago and also had a dental infection treated with antibiotics this week.

Known diagnosis of Graves' disease, managed with methimazole for the past 18 months. She ran out of her methimazole 2 weeks ago and did not refill it. This week she was started on amoxicillin for a dental abscess. No prior thyroid storm or hospitalization. She is not pregnant. No prior surgery. She smokes half a pack per day.

BP 168/76 mmHg (wide pulse pressure), HR 154 bpm (atrial fibrillation with rapid ventricular response), RR 28 breaths/min, Temp 40.4°C (104.7°F), SpO2 96% on room air. Patient is profusely diaphoretic, tremulous, and unable to follow commands reliably. Burch-Wartofsky Point Scale (BWPS) score: 75 (>45 highly suggestive of thyroid storm).

Thyroid storm suspected on clinical grounds — awaiting labs but treatment initiated immediately given severity. Propylthiouracil (PTU) 600mg via NG tube given as loading dose (blocks new hormone synthesis and peripheral T4-to-T3 conversion). One hour after PTU: Lugol's iodine solution given to block thyroid hormone release (must give PTU first to prevent iodine from being used to synthesize new hormone). IV propranolol 1mg slow push for rate control and symptom management. Hydrocortisone 300mg IV for adrenal support. Cooling blankets and acetaminophen for hyperthermia (NOT aspirin — displaces thyroid hormone from binding proteins).

TSH: <0.01 mIU/L (profoundly suppressed). Free T4: 5.8 ng/dL (critically elevated; normal 0.8–1.8 ng/dL). Free T3: 18.4 pg/mL (critically elevated; normal 2.3–4.2 pg/mL). WBC 14,200/µL (stress response). LFTs mildly elevated: AST 68, ALT 82. Glucose 218 mg/dL. Calcium 11.2 mg/dL (mild hypercalcemia from bone resorption). EKG: atrial fibrillation with rapid ventricular response at 148 bpm; no ischemic changes. Thyroid-stimulating immunoglobulins (TSI): markedly elevated — confirms Graves' disease.