Delirium physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]; Vishal Khurana, M.B.B.S., M.D. [3]

Overview

It is important to do a thorough physical examination to find out the underlying etiology of delirium.

Physical Examination

• Delirium symptom changes in severity during its course.
• It is essential to assess the patient multiple times, as it is easy to miss a diagnosis, also features like sundowning can be overlooked if the assessment is not done towards the end of the day.

General Examination

• Vital signs:

• Pulse: Increased pulse rate may be suggestive of heat failure, myocardial infarction or pulmonary pathology.
• Blood pressure: Malignant hypertension is an important cause of delirium, and blood pressure must be monitored if the patient is non compliant with antihypertensive medications.

• Low blood pressure may suggest heart failure.

• Appearance:

• Cherry red color indicates carbon monoxide poisoning,
• cyanosis may indicate respiratory or cardiac pathology.
• Jaundice may indicate hepatic or biliary pathology.
• Edema may be because of liver failure, cardiac failure, renal failure or malnutrition.

• Temperature:

• Fever may indicate underlying infection.

• Conscious level:

• Various levels of arousal can be seen in delirium, ranging from stupor to hyperarousal. If the patient appears to have a normal arousal level, attention deficit must be accessed which is very commonly seen in delirium.
• Cognitive function using a standardized screening tool, e.g. MoCA, Mini mental state examination

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• Nutritional status: B12 and folate deficiencies can be assessed on physical examination.
• Hydration state: Dehydration as well as an overload of fluids, resulting in hypoxia can cause delirium.
• Infectious foci: Careful examination to rule out conditions such as meningitis, encephalitis, pulmonary consolidation etc.
• Evidence of intoxication or withdrawal for alcohol, and recreational drugs are an important part of delirium work up. Look for tremors, pupil size, needle tracks etc.

Systemic Examination

• Focused examination is necessary to find out underlying etiology.

• Neurological examinations: Careful examination must be done to find out neurological causes of delirium, such as cerebrovascular diseases, neurodegenrative disorders such as parkinsonism, alzheimer, and lewi body dementia.

• Many systemic diseases may show neurological manifestations :hepatic encephalopathy causes [[flapping

• Overdose and intoxication can also effect the central nervous system : opiates causes pin point pupils and respiratory depression.

• Cardio-vascular examination: Examination of cardiovascular system is crucial in management of delirium. * * Careful heart auscultation may reveal underlying pathology.

• Frictional rub may suggest pericarditis.
• New onset murmur may be indicative of myocardial infarction.

• Pulmonaryexamination: Depressed respiration may be suggestive of drug overdose.

• Basal rales may be suggestive of cardiac failure.
• wheeze may be because of asthma or COPD.
• Increased tactile, vocal fermitus, egophony and dull on percussion may indicate underlying pneumonia.

• Abdominal examination: Ascitis may be suggestive of hepatic, renal or cardiac pathology. * * * Organomegaly may be indicative of portal hypertension and hepatic pathology.