<prompt> A young lady presents with tremors, diarrhea and elevated T4. TSH levels were 8.5 m lUL. Fuher examination reveals bi-temporal hemianopia. What is the next step of management?Sta anti-thyroid drugs, and do urgent MRI BrainSta beta blockersConservative managementSta anti-thyroid drugs and wait for symptoms to resolve  <response>: The clinical setting of high TSH and T4 with tremors and diarrhea signifies hypehyroidism due to either a TSH secreting pituitary tumor secondary hypehyroidism or elevated TRH secretion from hypothalamus teiary hypehyroidism. But the presence of Bi-temporal hemianopia localizes the lesion to Pituitary mass compressing the optic chiasma. Hence, the diagnosis is most likely TSH secreting Pituitary Adenoma. Radioiodine or anti-thyroid drugs can be used to control thyrotoxicosis and do urgent MRI to confirm the diagnosis. A combination of trans-sphenoidal surgery, sella irradiation, and octreotide may be required to normalize TSH, because many of these tumors are large and locally invasive at the time of diagnosis. 