Step 2: Detailed Physical Exam
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History and physical exam form the cornerstone of evaluation of a patient with delirium.
After obtaining patient history, conduct a detailed physical exam.
The physical exam should include but is not limited to:
- Vital signs
- include pulse oximetry and orthostatic vital signs whenever possible
- Pain assessment
- Assess for urinary retention or fecal impaction
- Encourage patient to undress fully
- Examine for signs of trauma, and any indwelling lines, ports, or drains. Evaluate for signs of infection in lungs, urine, CNS, abdomen, skin, and systemic infections
- Assess for signs for stroke, intracranial hemorrhage, seizures
- Check for sacral ulcers, rash, bruising
- Look for signs of abuse or neglect
- Abrasions, bruising, or trauma to back or upper arms, or patterns of injury concerning for NAT.
- Signs of poor care, lack of care, or neglect
- Assess for signs of drug overdose or withdrawal
NOTE:
If a patient is in withdrawal, physical examination will typically reveal autonomic arousal, with hypertension, fever, tachycardia, tongue and extremity tremor, pupillary dilatation, sweating and motor restlessness, or pronounced instability of vital signs.
Abbreviations
CNS, central nervous system