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, also features like sundowning can be overlooked if the assessment is not done in towards end of the day.
- General examination
- Systemic examination
General Examination
- Vitals:
- Pulse: Increased pulse rate may be suggestive of heat failure, myocardial infraction 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 antihypertension medications. Low blood pressure may suggest heart failure.
- Appearance: Cherry red color indicates CO poisoning, the cynosis may indicate respiratory or cardiac pathology. Jaundice may be indicative of hepatic or bilary pathology. Oedema may be because of liver failure, cardiac failure, renal failure or malnutrition.
- Temperature: Fever may be indicative of an underlying infection.
- 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, 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, alzhimers, and lewi body dementia etc. Many systemic diseases may show neurological manifestations, e.g.hepatic encephalopathy causes flapping tremors. Overdose and intoxication can also effect the central nervous system, e.g. 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 TVF, 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 hypertention and hepatic pathology.[1][2]