Delirium physical examination
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American Roentgen Ray Society Images of Delirium
It is important to do a thorough physical examination to find out the underlying etiology of delirium. Systemic physical examination includes testing vital signs such as temperature, pulse rate, blood pressure, and respiration and also evaluation of mental status. Patients may seem disoriented with difficulty in sustaining attention, problem in short-term memory, poor insight and impaired judgment.
- 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.
- 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.
- 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 or 4AT
- 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.
- 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.
- Careful heart auscultation may reveal underlying pathology.
- Frictional rub may suggest pericarditis.
- New onset murmur may be indicative of myocardial infarction.
- 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.
- 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.
- Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O'connor M; et al. (2021). "Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis". Age Ageing. 50 (3): 733–743. doi:10.1093/ageing/afaa224. PMC 8099016 Check
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