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{{Delirium}}
{{Delirium}}
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]; {{PB}}
{{CMG}}; {{AE}} {{Sara.Zand}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]


==Overview==
==Overview==
It is important to do a thorough physical examination to find out the underlying etiology 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]].
 
==Physical Examination==
==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.
* [[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
===General Examination===
*Systemic examination
* [[Vital signs]]:  
===General examination===
:*[[Pulse]]: Increased [[pulse rate]] may be suggestive of [[heat failure]], [[myocardial infarction]] or [[pulmonary]] pathology.
* Vitals:  
:*[[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]]. 
:*Temeperature
*[[Low blood pressure]] may suggest [[heart failure]].
:*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]]:  
:*Appearance: cherry red color indicates CO poisoning, the cynosis may indicate respiratory or cardiac pathology.  [[Jaundice]] may be indicative of hepatic or bilary pathology.
* [[Cherry red color]] indicates [[carbon monoxide]] poisoning,  
:*Temperature: fever may be indicative of an undelying infection.
* [[cyanosis]] 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.
* [[Jaundice]] may indicate [[hepatic]] or [[biliary]] pathology.   
* Cognitive function using a standardized screening tool, e.g. MOCA, MMSE
* [[Edema]] may be because of [[liver]] failure, [[cardiac]] failure, [[renal]] failure or [[malnutrition]].
:*Temperature:  
*[[Fever]] may indicate underlying [[infection]].
:* [[Conscious]] level:<ref name="pmid17488786">{{cite journal |vauthors=Bhat R, Rockwood K |title=Delirium as a disorder of consciousness |journal=J Neurol Neurosurg Psychiatry |volume=78 |issue=11 |pages=1167–70 |date=November 2007 |pmid=17488786 |pmc=2117593 |doi=10.1136/jnnp.2007.115998 |url=}}</ref>
* 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]]<ref name="LeesCorbet2013">{{cite journal|last1=Lees|first1=Rosalind|last2=Corbet|first2=Sinead|last3=Johnston|first3=Christina|last4=Moffitt|first4=Emma|last5=Shaw|first5=Grahame|last6=Quinn|first6=Terence J.|title=Test Accuracy of Short Screening Tests for Diagnosis of Delirium or Cognitive Impairment in an Acute Stroke Unit Setting|journal=Stroke|volume=44|issue=11|year=2013|pages=3078–3083|issn=0039-2499|doi=10.1161/STROKEAHA.113.001724}}</ref> or [https://www.the4at.com/ 4AT]<ref name="pmid33951145">{{cite journal| author=Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O'connor M | display-authors=etal| title=Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. | journal=Age Ageing | year= 2021 | volume= 50 | issue= 3 | pages= 733-743 | pmid=33951145 | doi=10.1093/ageing/afaa224 | pmc=8099016 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33951145  }} </ref>
{{#ev:youtube|_93i2xZQsd4}}
* Nutritional status: [[B12]] and [[folate]] deficiencies can be assessed on physical examination.
* 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.
* 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.
* 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.
* 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===
 
*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.<ref>{{Cite web | last = | first = | title = http://www.bgs.org.uk/Word%20Downloads/delirium.doc | url = http://www.bgs.org.uk/Word%20Downloads/delirium.doc | publisher =  | date =  | accessdate = }}</ref>
===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==
==References==

Latest revision as of 15:11, 27 May 2021

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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. 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.

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

  • Temperature:

{{#ev:youtube|_93i2xZQsd4}}

  • 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

References

  1. 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.
  2. 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.
  3. 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 |pmc= value (help). PMID 33951145 Check |pmid= value (help).

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