Delirium physical examination

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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

• Vital signs:

• 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.

• Appearance:

• 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:

• 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

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• 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.