TSH to evaluate for thyroid storm, which can present with tachycardia, hyperthermia, and acute psychosis requiring emergent endocrine intervention.

Thyroid storm is in the broad differential for hyperthermia with agitation, but the pupil dilation, visual hallucinations, and age make sympathomimetic intoxication far more likely.

CK, CMP/BMP, and EKG to assess for rhabdomyolysis, metabolic derangements, and cardiac arrhythmia in this sympathomimetic toxidrome presentation.

The clinical picture — dilated pupils, tachycardia, hypertension, hyperthermia, visual hallucinations, disorientation — is a sympathomimetic toxidrome. In an 18-year-old, stimulants (methamphetamine, cocaine), MDMA, and synthetic cathinones are high on the differential. Hyperthermia above 101°F with these vitals carries risk of rhabdomyolysis, DIC, and organ failure. CK assesses for rhabdomyolysis directly; CMP/BMP evaluates renal and metabolic status; EKG screens for arrhythmia. UDS may help identify the substance if available but has major limitations — many synthetic stimulants and novel substances are not detected on standard immunoassay panels. Treat clinically based on the toxidrome regardless of UDS results.

Prolactin level to differentiate primary psychosis from substance-induced psychosis, as an elevated prolactin would suggest a functional psychiatric disorder.

Prolactin levels have been studied as a psychosis differentiator but have limited clinical utility and are not the priority in an acutely unstable patient with abnormal vitals requiring medical stabilization.

Blood alcohol level to evaluate for alcohol withdrawal, since withdrawal-related hallucinations and autonomic instability can present with this clinical picture.

Alcohol withdrawal hallucinations are typically auditory, not visual with color distortion, and do not present with dilated pupils and this degree of hyperthermia. The toxidrome pattern points to sympathomimetic intoxication.