Delirium physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Khurana, M.B.B.S., M.D. [2]; Pratik Bahekar, MBBS [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 it's course. It's essential to assess patient multiple times, as it's easy to miss diagnosis, especially features like sundowning.

• General examination
• Systemic examination

General examination

• Vitals:

Temeperature Blood pressure: Malignant hypertension is an important cause of delirium, and blood pressure must be monitored if the patient is non compliant with antihypertension medications. Appearance: cherry red color indicates CO poisoning, the cynosis may indicate respiratory or cardiac pathology.

• Conscious level: Various levels of arousal can be seen in delirium, ranging from stupor to hperarousal. If the patient appears to have 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, MMSE
• 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 and pulmonary consolidation etc.
• Evidence of intoxication or withdrawal for alcohol, recreational drugs are an important part of delirium work up. Look for symptoms such as tremors, pupil size, and needle tracks etc.

Systemic examination

• Neurological examinations: Careful examination must be done to find out neurological causes of delirium, such as cerebrovascular diseases, neurodegenrative disorders such as parkinsonism, alzhimers, and lewi body dementia etc. Many systemic diseases may show neurological manifestations such as hepatic encephalopathy causes asterexis and flapping tremors. Overdose and intoxication can also effect the central nervous system, e.g. opiates causes pin point pupils, and respiratory depression.