Encephalopathy physical examination
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Encephalopathy |
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Diagnosis |
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Treatment |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
Physical examination includes complete review of all the systems. 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 Exam
Appearance of the Patient
The appearance is mainly depends upon the severity of the condition and the cause. The patient is often confused. The patient may appear anxious and may have difficulty in breathing. Bad odor may be felt at times due to fetor hepaticus in hepatic encephalopathy. There may few signs of injury which may be due to trauma.
Vitals
Temperature
- Increased in infections, thyroiditis
- Decreased in severe sepsis
Pulse
Rate
- Tachycardia may be present in cases of thyroiditis and infections
- Bradycardia may be present in dehydration, 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 of loss fluids , sepsis and low blood volume
- Hypertension may be present in cases of severe hypertensive encephalopathy
Respiratory Rate
- Tachypnea may be present in cases of pulmonary edema caused due to increase in blood pressure or due to multi organ failure
- Cheyne-Stokes respirations - an altered breathing pattern seen with brain damage and coma
Skin
- Cyanosis may be present in severe hypoxia and poisoning
- Jaundice may be present liver failure and in neonatal encephalopathy
- A rash may be present owing to a viral infection
Head
- No obvious signs on head.
- Skull fractures may be evident in cases of trauma
Eyes
- Icteric sclera may be present
- Nystagmus may be seen in a few cases of cranial nerve disease
- Papilledema, hemorrhages, exudates seen in hypertensive encephalopathy
Ears, Nose, Throat (ENT)
- No significant findings
- Injuries if trauma
Neck
- Jugular venous pressure may be elevated
- 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 tenderenss 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
Complete neurological examination may not be possible in a few cases due to disoriented presentation. The results of examination help in identifying the sire of lesion. Complete neurological exam include assessment of mental status, cranial nerves, motor system , sensation and cerebellum. 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
- Sensory system is not frequently involved in encephalopathies
Cerebellum
- Ataxia may be present
- Nystagmus may be present
- Asterixis may be present
- Gait abnormalities may be present