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The Differential

Get the Patient a Blanket!

Rick Tumminello, Medical Student, 10:39AM Feb 4, 2018

Rick Tumminello, MS, OMS-II, PCOM

I wanted to share an interesting case we had during my last rotation. I think it illustrates the importance of taking care of the basics and always going back to the vital signs. 


An 82 y/o white female presents to the ED with altered mental status (AMS). She does not appear to be in acute distress, and her eyes are open; she gradually becomes obtunded and minimally unresponsive. Per family, our patient has had a bout of recent hospitalizations: 22 days in April due to AMS and obtundation; AMS in September thought to be due to septic aspiration pneumonia; and generalized weakness with AMS and cough concerning for sepsis secondary to chronic sinusitis in November. Since then, she had episodes of confusion, on and off.

Vital signs

  • Temp - 86.5°F

  • BP - 134/88 mm Hg

  • HR - 34 beats/min

  • Oxygen saturation - 100% on room air

  • Respiratory rate - 17 breaths/min

Past medical history

  • Craniopharyngioma resection, subsequently developed panhypopituitarism from the surgery

  • Resultant panhypopituitarism and hypothalamic dysfunction with chronic hypothermia (baseline core temperature of 94.5°F)

  • Waxing and waning of cognition

  • Diabetes insipidus, requires desmopressin intranasally

  • Sodium level between 125-154 mEq/L, requires weekly basic metabolic panel

  • History of bradycardia 

  • Dysphagia requiring pureed diet with thickened liquids 

  • Sinus surgery (12/01/2017); chronic methicillin-resistant Staphylococcus aureus infection, which was susceptible to doxycycline 

  • Chronic kidney disease, stage 4 

Other findings

Lab results were only significant for an ECG that indicated sinus bradycardia with first-degree AV block. Our patient is on a boatload of medications, but sufficed to say she is being taken care of by an endocrinologist, neurologist, and primary care team to manage any hormonal deficiencies. 


The first thing we should've noticed was this patient's core temperature was 86.5°F. These patients commonly present with temperature dysregulation after surgery for craniopharyngioma. Patients suffer from several episodes of hypothermia associated with a decreased level of consciousness, hypoventilation, bradycardia, pancreatitis, and pancytopenia. Several case studies report that "rewarming resulted in complete recovery of all symptoms." That's right.

All this patient possibly needed was active rewarming. 

Several case reports go on ro describe patients who become poikilothermic following removal of a craniopharyngioma with episodes of disturbed behavior and neurologic abnormalities correlating with profound hypothermia.They examined the connection of chronic persistent hypothermia to patients with hypothalamic disease, tetraplegia, extensive dermatological disease, and recently as a late sequel to head injury.

So before you start worrying about efficiency of hormone replacements and consulting specialists, try rewarming any patient who presents with hypothermia post-craniopharyngioma resection.  

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  • Alina Khurgel
  • Kolin Meehan
  • Neil C. Bhavsar

    Medical Student 
    New Jersey Medical School

  • Rick Tumminello

    Philadelphia College of Osteopathic Medicine

  • Sung Woo Koh

    Chicago Medical School at Rosalind Franklin University

  • Heather Kagan

    Temple University School of Medicine, Philadelphia, PA

  • Stephanie Nguyen

    Temple University School of Medicine

    Philadelphia, PA

  • Vincent Migliaccio Michaelson

    O&Med School of Medicine|Havard Developed Pilot Program



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