Delirium physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Delirium}} | {{Delirium}} | ||
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com] | {{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 | * [[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=== | ||
* | * [[Vital signs]]: | ||
:*Blood pressure: [[Malignant hypertension]] is an important cause of delirium, and blood pressure must be monitored if the patient is non compliant with | :*[[Pulse]]: Increased [[pulse rate]] may be suggestive of [[heat failure]], [[myocardial infarction]] or [[pulmonary]] pathology. | ||
:*Appearance: | :*[[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]]. | ||
:*Temperature: | *[[Low blood pressure]] may suggest [[heart failure]]. | ||
* Conscious level: Various levels of arousal can be seen in delirium, ranging from stupor to | :* [[Appearance]]: | ||
* Cognitive function using a standardized screening tool, e.g. | * [[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: | |||
*[[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]], 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=== | ===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]], | * 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
- 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] or 4AT[3]
{{#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
- 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.
- ↑ 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).