A 75-year-old woman is seen in consultation prior to hip surgery. She fell on icy ground 36 hours ago and sustained an intertrochanteric right hip fracture. The patient lives independently. Her other medical problems include hypertension, osteoporosis, type 2 diabetes mellitus, and mild cognitive impairment.
Her right lower extremity is shortened and externally rotated, but physical examination is otherwise unremarkable.
Records indicate that her primary care provider obtained thyroid function tests a month ago as part of an evaluation for hypertension that showed the following:

Her current laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Question

A 75-year-old woman is seen in consultation prior to hip surgery.  She fell on icy ground 36 hours ago and sustained an intertrochanteric right hip fracture.  The patient lives independently.  Her other medical problems include hypertension, osteoporosis, type 2 diabetes mellitus, and mild cognitive impairment.
Her right lower extremity is shortened and externally rotated, but physical examination is otherwise unremarkable.
Records indicate that her primary care provider obtained thyroid function tests a month ago as part of an evaluation for hypertension that showed the following:

Her current laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97a2_5af8_853d_f5cd45c4b803_MD0002_00 This patient has subclinical hypothyroidism (elevated TSH with normal T₄), which can gradually progress to overt hypothyroidism over a period of many months to years. Overt hypothyroidism, especially when severe, is associated with an increased risk of perioperative complications (eg, atrial fibrillation). In addition, severe hypothyroidism due to autoimmune thyroiditis may coexist with adrenal insufficiency, which can further increase the risk of perioperative complications. However, subclinical hypothyroidism is not associated with a significant risk of adverse short-term outcomes. ₄ A delay in hip surgery >48-72 hours can impair rehabilitation and possibly increase postoperative complications. This patient is asymptomatic with a normal T₄ level; surgery should proceed with close clinical monitoring (Choices A and B). ₄ (Choices C and D) Intravenous thyroxine is usually given to patients with profound hypothyroidism, which is not present in this patient. Although untreated adrenal insufficiency can coexist with hypothyroidism, this patient's normal physical examination and laboratory results make this less likely. Educational objective: Subclinical hypothyroidism is relatively common in women age >60. Severe overt hypothyroidism is associated with an increased risk of surgical complications, but asymptomatic subclinical hypothyroidism does not warrant delay of urgent surgical procedures. __________ References: Thyroid status, cardiovascular risk and mortality in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/16507804) Subclinical hypothyroidism and cardiovascular risk: recommendations for treatment. (http://www.ncbi.nlm.nih.gov/pubmed/21983317)

A 75-Year-Old Woman Is Seen in Consultation Prior to Hip