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Psychiatric Emergencies for Clinicians: The Emergency Department Management of Thyroid Storm

  • Christopher S. Sharp
    Affiliations
    University of Colorado Denver, School of Medicine, Aurora, Colorado
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  • Michael P. Wilson
    Affiliations
    UC San Diego Health System, University of California, San Diego, California

    Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, University of California San Diego, San Diego, California
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  • Kimberly Nordstrom
    Correspondence
    Reprint Address: Kimberly Nordstrom, md, jd, Psychiatric Emergency Services, Denver Health Medical Center, 777 Bannock Street, Mailcode 0116, Denver, CO 80204
    Affiliations
    University of Colorado Denver, School of Medicine, Aurora, Colorado

    Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, University of California San Diego, San Diego, California

    Denver Health Medical Center, Department of Behavioral Health, Psychiatric Emergency Service, Denver, Colorado
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      A 54-year-old white woman with a history of depression is brought to the Emergency Department by police on an involuntary mental health hold secondary to out-of-control behavior. Police were contacted by her daughter, who reports the patient has not been sleeping and has become increasingly agitated. History is difficult to obtain, as on examination, her speech is pressured and illogical. Her daughter describes her behavior as a dramatic change over the last few days. On review of systems, she has a worsening cough and shortness of breath, fever, and 4 kg (∼9 lb) weight loss over the last few weeks. She appears jittery on observation, is pacing within the examination room, has a noticeable tremor, and is profusely diaphoretic. She also has a nonproductive cough. On physical examination, her vital signs include a temperature of 39.5°C (103°F), a heart rate of 135 beats/min, a blood pressure of 160/75 mm Hg, and a respiratory rate of 20 breaths/min, with an oxygen saturation of 96%. Her skin is noted for erythema and her palms are damp. Her lower extremities are notable for pitting edema. An electrocardiogram shows sinus tachycardia. Urine toxicology is negative. Metabolic panel and blood count are remarkable for leukocytosis (14.2 cells/L), hypercalcemia (11.7 mg/dL), and elevated transaminases (AST 287 U/L, ALT 245 U/L). She is oriented only to person. She becomes irritable with continued assessment and reports she needs to leave the hospital to give a presentation on world peace to the United Nations. When told she cannot leave, she becomes agitated and assaults a staff member, requiring physical restraints.

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