TAILIEUCHUNG - Chapter 026. Confusion and Delirium (Part 4)

Physical Examination The general physical examination in a delirious patient should include a careful screening for signs of infection such as fever, tachypnea, pulmonary consolidation, heart murmur, or stiff neck. The patient's fluid status should be assessed; both dehydration and fluid overload with resultant hypoxia have been associated with delirium, and each is usually easily rectified. The appearance of the skin can be helpful, showing jaundice in hepatic encephalopathy, cyanosis in hypoxia, or needle tracks in patients using intravenous drugs. The neurologic examination requires a careful assessment of mental status. Patients with delirium often present with a fluctuating course; therefore the. | Chapter 026. Confusion and Delirium Part 4 Physical Examination The general physical examination in a delirious patient should include a careful screening for signs of infection such as fever tachypnea pulmonary consolidation heart murmur or stiff neck. The patient s fluid status should be assessed both dehydration and fluid overload with resultant hypoxia have been associated with delirium and each is usually easily rectified. The appearance of the skin can be helpful showing jaundice in hepatic encephalopathy cyanosis in hypoxia or needle tracks in patients using intravenous drugs. The neurologic examination requires a careful assessment of mental status. Patients with delirium often present with a fluctuating course therefore the diagnosis can be missed when relying on a single time point of evaluation. Some but not all patients exhibit the characteristic pattern of sundowning a worsening of their condition in the evening. In these cases assessment only during morning rounds may be falsely reassuring. An altered level of consciousness ranging from hyperarousal to lethargy to coma is present in most patients with delirium and can be easily assessed at the bedside. In the patient with a relatively normal level of consciousness a screen for an attentional deficit is in order as this deficit is the classic neuropsychological hallmark of delirium. Attention can be assessed while taking a history from the patient. Tangential speech a fragmentary flow of ideas or inability to follow complex commands often signifies an attentional problem. Formal neuropsychological tests to assess attention exist but a simple bedside test of digit span forward is quick and fairly sensitive. In this task patients are asked to repeat successively longer random strings of digits beginning with two digits in a row. Average adults can repeat a string of between five to seven digits before faltering a digit span of four or less usually indicates an attentional deficit unless hearing or .

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