Delirium physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]; Vishal Khurana, M.B.B.S., M.D. [4]
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
- 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.
- 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:
- 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[2]
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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 tremor.
- 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.
- Pulmonary examination: 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.
References
- ↑ Bhat R, Rockwood K (November 2007). "Delirium as a disorder of consciousness". J Neurol Neurosurg Psychiatry. 78 (11): 1167–70. doi:10.1136/jnnp.2007.115998. PMC 2117593. PMID 17488786.
- ↑ Lees, Rosalind; Corbet, Sinead; Johnston, Christina; Moffitt, Emma; Shaw, Grahame; Quinn, Terence J. (2013). "Test Accuracy of Short Screening Tests for Diagnosis of Delirium or Cognitive Impairment in an Acute Stroke Unit Setting". Stroke. 44 (11): 3078–3083. doi:10.1161/STROKEAHA.113.001724. ISSN 0039-2499.