What is the appropriate evaluation and management for a 69‑year‑old man with hyperlipidemia, hypertension, type 2 diabetes mellitus, prostate cancer and a thyroid nodule who presents with hypothermia (temperature 94.8 °F) and ear pain?

Immediate Evaluation and Management of Hypothermia with Ear Pain

This patient requires urgent assessment and treatment of hypothermia (94.8°F/34.9°C) as the primary concern, with concurrent evaluation of the ear pain as a potential infectious source or unrelated complaint.

Priority 1: Address Hypothermia Immediately

The temperature of 94.8°F represents moderate hypothermia and takes precedence over the ear complaint due to potential life-threatening complications.

Immediate Actions for Hypothermia:

• Remove wet clothing and initiate passive external rewarming with blankets and warm environment
• Assess for altered mental status, cardiac arrhythmias, and hemodynamic instability which are critical complications of hypothermia
• Obtain core temperature measurement (rectal, esophageal, or bladder probe) as peripheral measurements may underestimate severity
• Continuous cardiac monitoring as hypothermia increases risk of atrial fibrillation and ventricular arrhythmias
• Check blood glucose immediately given his diabetes, as hypoglycemia can both cause and complicate hypothermia

Evaluate Underlying Causes:

• Assess for sepsis or infection (including the ear as potential source) - infection can cause hypothermia in elderly diabetic patients
• Review medications - particularly diabetes medications that could cause hypoglycemia, antihypertensives causing decreased perfusion
• Evaluate thyroid function given the known thyroid nodule - hypothyroidism can present with hypothermia and should be assessed with TSH 1, 2
• Screen for environmental exposure or inadequate home heating

Priority 2: Evaluate Ear Pain

Diagnostic Approach for Ear Pain:

• Perform otoscopic examination to differentiate between:
  • External otitis (ear canal inflammation/infection)
  • Otitis media (middle ear infection)
  • Malignant otitis externa (particularly concerning in diabetic patients)

Key Considerations in Diabetic Patients:

• Malignant (necrotizing) external otitis is a medical emergency in diabetic patients, typically caused by Pseudomonas aeruginosa
• Look for severe otalgia, purulent otorrhea, granulation tissue in ear canal, and cranial nerve involvement
• If suspected, obtain CT temporal bone and ENT consultation urgently

Priority 3: Address Comorbidity Interactions

Diabetes Management During Acute Illness:

• Monitor blood glucose closely as acute illness and hypothermia alter glucose metabolism 3
• Adjust diabetes medications temporarily if patient is unable to eat or has altered mental status
• Assess for diabetic ketoacidosis or hyperosmolar state if glucose is significantly elevated

Thyroid Nodule Considerations:

• Measure TSH as the initial thyroid function test to evaluate for hypothyroidism as a contributor to hypothermia 1, 2, 4
• If TSH is elevated, this confirms hypothyroidism which requires thyroid hormone replacement and explains hypothermia
• The thyroid nodule itself is not the acute issue but underlying thyroid dysfunction may be

Common Pitfalls to Avoid:

• Do not focus solely on the ear pain while missing life-threatening hypothermia
• Do not assume environmental exposure without ruling out metabolic causes (hypothyroidism, hypoglycemia, sepsis)
• Do not overlook malignant otitis externa in diabetic patients with ear pain - this requires aggressive treatment
• Do not rewarm too rapidly if moderate-to-severe hypothermia, as this can cause rewarming shock and arrhythmias
• Do not discharge until core temperature normalizes and underlying cause is identified

Disposition:

This patient requires hospital admission for:

• Monitored rewarming
• Treatment of underlying cause of hypothermia
• Management of potential infection (ear or systemic)
• Evaluation of thyroid function and diabetes control