Thursday, June 21, 2012

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Delirium - definition, common causes, physical examination


Definition:
Delirium is defined by the acute onset of fluctuating cognitive impairment and a disturbance of consciousness. Cognition includes memory, language, orientation, judgement, conducting interpersonal relationships, performing actions (praxis), and problem solving. Delirium is thus marked by short-term confusion and changes in cognition. There is also rapid improvement in most cases when the causative factor is identified and eliminated.

Abnormalities of mood, perception, and behavior are common psychiatric symptoms. Tremor, asterixis, nystagmus, incoordination, and urinary incontinence are common neurological symptoms.

Common causes of delirium:
1) Central nervous system disorder
Seizure (postictal, nonconvulsive status, status)
Migraine
Head trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia
2) Metabolic disorder
Electrolyte abnormalities
Diabetes, hypoglycemia, hyperglycemia, or insulin resistance
3) Systemic illness
Infection (e.g., sepsis, malaria, erysipelas, viral, plague, Lyme disease, syphilis, or abscess)
Trauma
Change in fluid status (dehydration or volume overload)
Nutritional deficiency
Burns
Uncontrolled pain
Heat stroke
High altitude (usually >5,000 m)
4) Medications
Pain medications (e.g., postoperative meperidine or morphine)
Antibiotics, antivirals, and antifungals
Steroids
Anesthesia
Cardiac medications
Antihypertensives
Antineoplastic agents
Anticholinergic agents
Neuroleptic malignant syndrome
Serotonin syndrome
5) Over-the-counter preparations
Herbals, teas, and nutritional supplements
6) Botanicals
Jimsonweed, oleander, foxglove, hemlock, dieffenbachia, and Amanita phalloides
7) Cardiac
Cardiac failure, arrhythmia, myocardial infarction, cardiac assist device, cardiac surgery
8) Pulmonary
Chronic obstructive pulmonary disease, hypoxia, SIADH, acid base disturbance
9) Endocrine
Adrenal crisis or adrenal failure, thyroid abnormality, parathyroid abnormality
10) Hematological
Anemia, leukemia, blood dyscrasia, stem cell transplant
11) Renal
Renal failure, uremia, SIADH
12) Hepatic
Hepatitis, cirrhosis, hepatic failure
13) Neoplasm
Neoplasm (primary brain, metastases, paraneoplastic syndrome)
14) Drugs of abuse
Intoxication and withdrawal
15) Toxins
Intoxication and withdrawal
Heavy metals and aluminum




Physical examination of a delirious patient:




Parameter
Finding
Clinical Implication

1. Pulse
Bradycardia
Hypothyroidism
Stokes-Adams syndrome
Increased intracranial pressure

Tachycardia
Hyperthyroidism
Infection
Heart failure

2. Temperature
Fever
Sepsis
Thyroid storm
Vasculitis

3. Blood pressure
Hypotension
Shock
Hypothyroidism
Addison's disease

Hypertension
Encephalopathy
Intracranial mass

4. Respiration
Tachypnea
Diabetes
Pneumonia
Cardiac failure
Fever
Acidosis (metabolic)

Shallow
Alcohol or other substance intoxication

5. Carotid vessels
Bruits or decreased pulse
Transient cerebral ischemia

6. Scalp and face
Evidence of trauma

7. Neck
Evidence of nuchal rigidity
Meningitis
Subarachnoid hemorrhage

8. Eyes
Papilledema
Tumor
Hypertensive encephalopathy

Pupillary dilatation
Anxiety
Autonomic overactivity (e.g., delirium tremens)

9. Mouth
Tongue or cheek lacerations
Evidence of generalized tonic-clonic seizures

10. Thyroid
Enlarged
Hyperthyroidism

11. Heart
Arrhythmia
Inadequate cardiac output, possibility of emboli

Cardiomegaly
Heart failure
Hypertensive disease

12. Lungs
Congestion
Primary pulmonary failure
Pulmonary edema
Pneumonia

13. Breath
Alcohol

Ketones
Diabetes

14. Liver
Enlargement
Cirrhosis
Liver failure

15. Nervous system
a. Reflexes
Asymmetry with Babinski's signs
Mass lesion
Cerebrovascular disease
Preexisting dementia
Snout
Frontal mass
Bilateral posterior cerebral artery occlusion
b. Abducent nerve
(sixth cranial nerve)
Weakness in lateral gaze
Increased intracranial pressure
c. Limb strength
Asymmetrical
Mass lesion
Cerebrovascular disease
d. Autonomic
Hyperactivity
Anxiety
Delirium

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