Encephalopathy physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
A comprehensive physical examination is necessary in a patient with suspected encephalopathy. Clues to diagnosis are obtained from physical examination, such as any skull fractures would indicate trauma as the cause, signs of liver failure may identify hepatic encephalopathy as the cause. In cases of a brain lesion, a complete neurological examination may identify the site of the lesion. | |||
==Physical Examination== | |||
==Appearance of the Patient== | ==Appearance of the Patient== | ||
The appearance | The general appearance of the patient will depend on the severity of the condition, and the cause. The patient is often confused, and may appear anxious and with difficulty breathing. Bad breath may be noticed in cases with fetor hepaticus due to hepatic encephalopathy. If trauma is the cause of encephalopathy, this may be apparent on first glance. | ||
==Vitals== | ==Vitals== | ||
===Temperature=== | ===Temperature=== | ||
* Increased in | * Increased in cases of infectious encephalopathy, and thyroiditis as the cause. | ||
* Decreased in severe sepsis. | |||
===Pulse=== | ===Pulse=== | ||
====Rate==== | ====Rate==== | ||
*[[Tachycardia]] may be present in | *[[Tachycardia]] may be present in persons with thyroiditis and infection. | ||
*[[Bradycardia]] may be present in dehydration, loss of blood volume and severe sepsis | *[[Bradycardia]] may be present in dehydration as a cause, and loss of blood volume and severe sepsis. | ||
====Rhythm==== | ====Rhythm==== | ||
*The pulse is regular | *The pulse is regular. | ||
====Strength==== | ====Strength==== | ||
*The pulse may be weak in cases of dehydration and hemorrhages | *The pulse may be weak in cases of dehydration and hemorrhages. | ||
====Symmetry==== | ====Symmetry==== | ||
*The pulses are symmetric | *The pulses are symmetric. | ||
===Blood Pressure=== | ===Blood Pressure=== | ||
*[[Hypotension]] may be present in cases of | *[[Hypotension]] may be present in cases where there is a negative fluid balance, cases of sepsis, and low blood volume. | ||
*[[Hypertension]] may be present in cases of severe hypertensive encephalopathy | *[[Hypertension]] may be present in cases of severe hypertensive encephalopathy. | ||
===Respiratory Rate=== | ===Respiratory Rate=== | ||
*[[Tachypnea]] may be present in cases of | *[[Tachypnea]] may be present in cases of hypoxic encephalopathy. | ||
* [[Cheyne-Stokes respirations]] - an altered breathing pattern can be seen in cases of encephalopathy due to brain damage and coma. | |||
* [[Cheyne-Stokes respirations]] - an altered breathing pattern seen | |||
==Skin== | ==Skin== | ||
*[[Cyanosis]] may be | *[[Cyanosis]] may be seen in severe hypoxia and poisoning. | ||
*[[Jaundice]] may be | *[[Jaundice]] may be seen in liver failure and in neonatal encephalopathy. | ||
* A rash may be present | * A rash may be present encephalopathy due to viral infection. | ||
==Head== | ==Head== | ||
* Skull fractures may be evident in cases of trauma. | |||
* Skull fractures may be evident in cases of trauma | |||
==Eyes== | ==Eyes== | ||
* [[Icteric sclera]] may be | * [[Icteric sclera]] may be seen in cases of hepatic encephalopathy. | ||
* [[Nystagmus]] may be seen in | * [[Nystagmus]] may be seen in encephalopathy leading to cranial nerve dysfunction. | ||
* [[Papilledema]], [[hemorrhages]], [[exudates]] | * [[Papilledema]], [[hemorrhages]], [[exudates]] can be seen in hypertensive encephalopathy. | ||
==Ears, Nose, Throat (ENT)== | ==Ears, Nose, Throat (ENT)== | ||
* Injuries may be seen if there is trauma to the head. | |||
* Injuries if trauma | * Signs of infection (redness and exudate) may be seen in encepalopathy as a result of infection. | ||
*Dry mucous membranes may be seen in encephalopathy due to hypovolemia. | |||
==Neck== | ==Neck== | ||
*[[Jugular venous pressure]] may be elevated | *[[Jugular venous pressure]] may be elevated due to portal hypertension. | ||
*[[Thyromegaly]] may be present | *[[Thyromegaly]] may be present. | ||
==Lungs== | ==Lungs== | ||
*[[Pulmonary edema]] and [[rales]] may be present | *[[Pulmonary edema]] and [[rales]] may be present. | ||
* Lung consolidation - in case of infections | * Lung consolidation - in case of infections. | ||
==Heart== | ==Heart== | ||
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] Normal | *[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] Normal.. | ||
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] Normal | *[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] Normal. | ||
*[[Heart sounds#Third heart sound S3|S3]] may be heard in hypertensive cases | *[[Heart sounds#Third heart sound S3|S3]] may be heard in hypertensive cases. | ||
==Abdomen== | ==Abdomen== | ||
Significant abdominal findings are seen in [[hepatic encephalopathy]] | Significant abdominal findings are seen in [[hepatic encephalopathy]] | ||
*[[Abdominal distention]] may be present | *[[Abdominal distention]] may be present. | ||
*[[Abdominal | *[[Abdominal tenderness]] may be present if any infections like [[spontaneous bacterial peritonitis]]. | ||
*An [[acute abdomen]] may be present | *An [[acute abdomen]] may be present. | ||
*[[Splenomegaly]] may be present in [[cirrhosis]] | *[[Splenomegaly]] may be present in [[cirrhosis]]. | ||
* Abdominal pulsations can be noticed in hepatic encephalopathy | * Abdominal pulsations can be noticed in hepatic encephalopathy. | ||
==Extremities== | ==Extremities== | ||
* [[Edema]] may be | * [[Edema]] may be seen. | ||
* [[Cyanosis]] may evident in the patients of hypoxia | * [[Cyanosis]] may evident in the patients of hypoxia. | ||
==Neurologic== | ==Neurologic== | ||
A complete neurological examination may not be possible in some cases due to disoriented presentation. The results of neurological examination can help in identifying the site of lesion. Complete neurological exam includes assessment of mental status, cranial nerve function, motor system function, deficits in sensation and cerebellar functions. All the signs listed below may not be seen in all encephalopathy patients. | |||
===Mental status=== | |||
* Assessment of consciousness by Glasgow Coma Scale , this determines the alertness of the patient. | |||
* Assessment of higher functions like memory. | |||
* Assessment of mental status by Mini Mental Status Examination. | |||
*[[ | ===Cortical signs=== | ||
*[[ | * Psychomotor retardition. | ||
*[[ | * [[Dementia]]. | ||
* | * [[Apraxia]]. | ||
* | * [[Mutism]]. | ||
* | These signs are seen in terminal stages of untreated encephalopathy. | ||
*[[Loss of ability to swallow]] | ===Cranial nerves=== | ||
* [[Nystagmus]] may be seen. | |||
* Visual acuity or visual field defects. | |||
* Facial nerve palsy. | |||
*[[Loss of ability to swallow]]. | |||
*[[Loss of ability to speak]] | *[[Loss of ability to speak]] | ||
===Motor system=== | |||
* Muscle [[atrophy]] and weakness. | |||
* [[Myoclonus]] (involuntary twitching of a muscle or group of muscles). | |||
* [[Tremor]]. | |||
* [[Seizure]]. | |||
* No abnormal postures. | |||
* [[Hyperreflexia]]. | |||
Any other motor system signs point towards other differential diagnosis. | |||
===Sensations=== | |||
* The sensory system is not usually involved in encephalopathy. | |||
===Cerebellum=== | |||
* [[Ataxia]] may be present. | |||
* [[Nystagmus]] may be present. | |||
* [[Asterixis]] may be present. | |||
* Gait abnormalities may be present. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
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{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category: | |||
[[Category:Physical examination]] | |||
Latest revision as of 14:42, 10 August 2012
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Encephalopathy |
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Diagnosis |
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Treatment |
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Encephalopathy physical examination On the Web |
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American Roentgen Ray Society Images of Encephalopathy physical examination |
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Risk calculators and risk factors for Encephalopathy physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
A comprehensive physical examination is necessary in a patient with suspected encephalopathy. Clues to diagnosis are obtained from physical examination, such as any skull fractures would indicate trauma as the cause, signs of liver failure may identify hepatic encephalopathy as the cause. In cases of a brain lesion, a complete neurological examination may identify the site of the lesion.
Physical Examination
Appearance of the Patient
The general appearance of the patient will depend on the severity of the condition, and the cause. The patient is often confused, and may appear anxious and with difficulty breathing. Bad breath may be noticed in cases with fetor hepaticus due to hepatic encephalopathy. If trauma is the cause of encephalopathy, this may be apparent on first glance.
Vitals
Temperature
- Increased in cases of infectious encephalopathy, and thyroiditis as the cause.
- Decreased in severe sepsis.
Pulse
Rate
- Tachycardia may be present in persons with thyroiditis and infection.
- Bradycardia may be present in dehydration as a cause, and loss of blood volume and severe sepsis.
Rhythm
- The pulse is regular.
Strength
- The pulse may be weak in cases of dehydration and hemorrhages.
Symmetry
- The pulses are symmetric.
Blood Pressure
- Hypotension may be present in cases where there is a negative fluid balance, cases of sepsis, and low blood volume.
- Hypertension may be present in cases of severe hypertensive encephalopathy.
Respiratory Rate
- Tachypnea may be present in cases of hypoxic encephalopathy.
- Cheyne-Stokes respirations - an altered breathing pattern can be seen in cases of encephalopathy due to brain damage and coma.
Skin
- Cyanosis may be seen in severe hypoxia and poisoning.
- Jaundice may be seen in liver failure and in neonatal encephalopathy.
- A rash may be present encephalopathy due to viral infection.
Head
- Skull fractures may be evident in cases of trauma.
Eyes
- Icteric sclera may be seen in cases of hepatic encephalopathy.
- Nystagmus may be seen in encephalopathy leading to cranial nerve dysfunction.
- Papilledema, hemorrhages, exudates can be seen in hypertensive encephalopathy.
Ears, Nose, Throat (ENT)
- Injuries may be seen if there is trauma to the head.
- Signs of infection (redness and exudate) may be seen in encepalopathy as a result of infection.
- Dry mucous membranes may be seen in encephalopathy due to hypovolemia.
Neck
- Jugular venous pressure may be elevated due to portal hypertension.
- Thyromegaly may be present.
Lungs
- Pulmonary edema and rales may be present.
- Lung consolidation - in case of infections.
Heart
Abdomen
Significant abdominal findings are seen in hepatic encephalopathy
- Abdominal distention may be present.
- Abdominal tenderness may be present if any infections like spontaneous bacterial peritonitis.
- An acute abdomen may be present.
- Splenomegaly may be present in cirrhosis.
- Abdominal pulsations can be noticed in hepatic encephalopathy.
Extremities
Neurologic
A complete neurological examination may not be possible in some cases due to disoriented presentation. The results of neurological examination can help in identifying the site of lesion. Complete neurological exam includes assessment of mental status, cranial nerve function, motor system function, deficits in sensation and cerebellar functions. All the signs listed below may not be seen in all encephalopathy patients.
Mental status
- Assessment of consciousness by Glasgow Coma Scale , this determines the alertness of the patient.
- Assessment of higher functions like memory.
- Assessment of mental status by Mini Mental Status Examination.
Cortical signs
These signs are seen in terminal stages of untreated encephalopathy.
Cranial nerves
- Nystagmus may be seen.
- Visual acuity or visual field defects.
- Facial nerve palsy.
- Loss of ability to swallow.
- Loss of ability to speak
Motor system
- Muscle atrophy and weakness.
- Myoclonus (involuntary twitching of a muscle or group of muscles).
- Tremor.
- Seizure.
- No abnormal postures.
- Hyperreflexia.
Any other motor system signs point towards other differential diagnosis.
Sensations
- The sensory system is not usually involved in encephalopathy.
Cerebellum
- Ataxia may be present.
- Nystagmus may be present.
- Asterixis may be present.
- Gait abnormalities may be present.