Encephalopathy physical examination

A comprehensive physical examination is necessary in a patient with suspected encephalopathy. 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.

The general appearance of the patient will depend on the severity of the condition, and the cause. The patient is often confused, and may appear anxious and with difficulty breathing. Bad breath may be noticed in cases with fetor hepaticus due to hepatic encephalopathy. If trauma is the cause of encephalopathy, this may be apparent on first glance.

• Increased in cases of infectious encephalopathy, and thyroiditis as the cause.

• Decreased in severe sepsis.

• Tachycardia may be present in persons with thyroiditis and infection.
• Bradycardia may be present in dehydration as a cause, and loss of blood volume and severe sepsis.

• The pulse is regular.

• The pulse may be weak in cases of dehydration and hemorrhages.

• The pulses are symmetric.

• Hypotension may be present in cases where there is a negative fluid balance, cases of sepsis, and low blood volume.
• Hypertension may be present in cases of severe hypertensive encephalopathy.

• Tachypnea may be present in cases of hypoxic encephalopathy.
• Cheyne-Stokes respirations – an altered breathing pattern can be seen in cases of encephalopathy due to brain damage and coma.

• Cyanosis may be seen in severe hypoxia and poisoning.
• Jaundice may be seen in liver failure and in neonatal encephalopathy.
• A rash may be present encephalopathy due to viral infection.

• Skull fractures may be evident in cases of trauma.

• Icteric sclera may be seen in cases of hepatic encephalopathy.
• Nystagmus may be seen in encephalopathy leading to cranial nerve dysfunction.
• Papilledema, hemorrhages, exudates can be seen in hypertensive encephalopathy.

• Injuries may be seen if there is trauma to the head.
• Signs of infection (redness and exudate) may be seen in encepalopathy as a result of infection.
• Dry mucous membranes may be seen in encephalopathy due to hypovolemia.

• Jugular venous pressure may be elevated due to portal hypertension.
• Thyromegaly may be present.

• Pulmonary edema and rales may be present.
• Lung consolidation – in case of infections.

• S1 Normal..
• S2 Normal.
• S3 may be heard in hypertensive cases.

Significant abdominal findings are seen in hepatic encephalopathy

• Abdominal distention may be present.
• Abdominal tenderness 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.

• Edema may be seen.
• Cyanosis may evident in the patients of hypoxia.

A complete neurological examination may not be possible in some cases due to disoriented presentation. The results of neurological examination can help in identifying the site of lesion. Complete neurological exam includes assessment of mental status, cranial nerve function, motor system function, deficits in sensation and cerebellar functions. All the signs listed below may not be seen in all encephalopathy patients.

• 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.

• Psychomotor retardition.
• Dementia.
• Apraxia.
• Mutism.

These signs are seen in terminal stages of untreated encephalopathy.

• Nystagmus may be seen.
• Visual acuity or visual field defects.
• Facial nerve palsy.
• Loss of ability to swallow.
• Loss of ability to speak

• 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.

• The sensory system is not usually involved in encephalopathy.

• Ataxia may be present.
• Nystagmus may be present.
• Asterixis may be present.
• Gait abnormalities may be present.

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