A patient with bipolar I disorder is currently being managed with lithium, 60 mg q.h.s. along with quetiapine 300 mg daily. The patient presents today for follow-up and reports that her mood has been very stable. Her work as a pastry chef has been really stressful around the holiday season, but she has handled it well and has no concerns about any mood deviations, either manic or depressive. She is sleeping approximately 7 hours nightly. Her last blood work was 7 months ago, and at the time there were no alarm findings in her lithium level, renal function tests, TSH, or liver function tests. On physical examination the PMHNP appreciates a fine, symmetrical tremor of the hands that gets worse when the NP asks her to write her name. This finding was not present on previous examinations. 

The NP should take which of the following actions? 

A. Draw a TSH, lithium level, and metabolic panel with eGFR in the office today 

B. Instruct the patient to proceed to the emergency room immediately   

C. Hold the lithium and order a lithium level to be drawn in one week. 

D. Hold the quetiapine and order a metabolic panel with eGFR in one week. 

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