Physical Exam and Lab Investigations in patients with Substance Use Disorder
Posted by dkwinter

Physical Exam:

  • Hepatosplenomegaly
  • Cardiovascular status
  • Respiratory status
  • Needle track marks
  • Documented baseline mental status examination
  • Some signs and symptoms of intoxication include the following:
    • Euphoria, dysphoria, motor retardation, sedation, pinpoint pupils, slowed speech
  • Physical complications of injection
    • Risk of pneumonia, endocarditis, cardiovascular complications, skin and soft tissue infections, as well as pulmonary complications of smoking drugs
  • Baseline assessment of breath and heart sounds
    • For present or future risk of pneumonia, endocarditis, or TB
  • ​Physical evidence of chronic liver disease (this population has a high risk of hepatitis C):
    • Signs and symptoms of liver disease:
      • Jaundice, liver enlargement
      • Abdominal swelling (due to ascites), pruritus (itching)
      • Unexplained weight loss
      • Abdominal pain, fatigue, not feeling well, loss of appetite
      • Note: Additionally, alcohol use is very common in this patient group and therefore warrants routine monitoring for complications of alcohol use, including tremor or cerebellar dysfunction
  • Neurological screening:
    • Routine tests include tandem gait and finger-to-nose pointing to evaluate complications of alcohol use
  • Evidence of opportunistic infections:
    • Infections including thrush, cytomegalovirus (CMV) retinitis, or Kaposi’s sarcoma may indicate compromised immune function due to undiagnosed HIV infection
  • Other comorbid or chronic health problems documented in patient’s medical history


Laboratory Investigations:

  • Complete blood count (CBC)
    • mean corpuscular volume (MCV)*
  • gamma-glutamyl transferase (GGT)*      *To determine general health, assess possible co-morbidities, rule out illness and gauge alcohol consumption
  • Liver function tests (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) -- To evaluate effects of alcohol and viral hepatitis
  • Hepatitis serology
  • HIV serology
  • Pregnancy test
  • Urine toxicology
  • Tuberculosis (TB) skin test


Urine Drug Screening

  • Performed at the time of the initial assessment and on a fixed or random schedule throughout the course of treatment
  • Frequency of urine test varies and needs to be individualized.