CASE PRESENTATION: We present a 42 year old female with Graves’ disease with a history of thyroid storm, schizophrenia and non-compliance with medications who was brought to the ED to obtain medical clearance for psychiatric treatment. She was exhibiting hostile, bizarre and paranoid behavior. She refused all medical care and was involuntarily committed for mental and physical care. Upon arrival, her BP was 161/96, HR 156, RR 22, Temp 37.4oC, Sat 98% on RA. A large goiter was visible. She endorsed symptoms of cough and shortness of breath but denied fever, chills, chest pain or hemoptysis. Blood work showed a TSH <0.01, T4 free 3.98, and T3 total 800.64. Impending thyroid storm was diagnosed and treatment was initiated with propylthiouracil, propranolol and hydrocortisone. Her mood improved, she was less hostile, and more cooperative with medical treatments; however, her dyspnea remained unchanged. Diagnostic workup included a normal CXR, thyroid US showing heterogeneous enlargement, and a V/Q scan resulting in low probability for PE. Echocardiogram showed a hyper dynamic LV, mildly dilated RV with PASP >70mmHg. She was deemed a poor candidate for long term medical therapy and a decision was made for total thyroidectomy during this admission once the patient achieved a euthyroid state. Her symptoms remained stable and surgery was performed 2 weeks after admission. Her dyspnea quickly improved and repeat measurements showed an improved PASP of 50mmHg.