Drug Therapy and Physical Assessment

(Adapted from: Eisenhauer, L. A. & Murphy, M. A. (1998). Pharmacotherapeutics and advanced nursing practice. NY: McGraw-Hill.)

Physical assessment is an integral part of any encounter of the clinician and the patient. The extent and focus of physical assessment depends on the circumstances. A brief and focused assessment may be done when monitoring specific aspects of a patient's ongoing drug and other therapy or when investigating a specific complaint. A general overall assessment is used is order to evaluate overall health status.

The drug therapy that a patient is receiving may impact on the findings of physical assessment. The purpose of this page is to highlight the effects of commonly used drugs on physical examination findings. Some of these effects are interferences i.e., they are drug side effects that might lead to a confused or perhaps erroneous or dangerous conclusion if the clinician did not realize that the effects were from the drug therapy. Not all of these effects are necessarily benign; many require some type of followup as to whether it is affecting the patient's quality of life or functioning or needs to be treated to prevent further damage.

Since drugs can cause so many different adverse effects and may actually cause disease, it is sometimes difficult to make a clear distinction between interferences or inconvenient side effects and signs of actual adverse effects caused by a drug.


Overall General Assessment -

Observing the patient as he or she walks into a room can give clues to ataxia and other gait disturbances that may be a result of such drugs as ototoxics (eg. antibiotics, loop diuretics), antipsychotics(e.g. tardive dyskinesia) or peripheral neuropathy (INH).

As the clinician begins to interact with the patient clues to mental status and the mental and physical ability to follow directions can be assessed as the examination progresses

Facies: masklike- may indicate pseudoparkinsonism from antipsychotics.

Cushingoid moon face, buffalo hump, trunkal fat deposits) may indicate the patient is on steroid therapy.
smacking of lips, gyrations of tongue, grimacing: tardive dyskinesia ?

Skin
Skin eruptions are commonly caused by drugs and may indicate allergic responses. Drug therapy should always be considered as a possible cause of any skin eruption.

Discoloration of skin
Dark hyperpigmentation- chlorpromazine
Jaundice may be from drug induced liver damage or from drug induced cholestasis(phenothiazines, INH, tetracycline)
Brown: quinacrine
Gray- deposition of metallic salts- silver, gold, bismuth
Pigmentation ("melasma of pregnancy"): oral contraceptives,

Dryness: anticholinergics, other drugs with anticholinergic side effects(e.g.. psychotropics)

Bruising: anticoagulants, aspirin, steroids, any drugs causing bone marrow depression (antibiotics, cancer chemotherapy)

Thinning, striae and darkening of skin: steroids

Scarring, needle tracks: cue to drug abuse

Contact dermatitis- from direct skin contact with drug or chemical e.g. aminoglycosides

Acne: suggests changes in sex hormone levels.

Livedo reticularis -reddish-blue net-like pattern- amantadine

Yellow or orange stain on soles or palms: isotretinoin or rifampin or excessive ingestion of foods rich in carotene.

Red neck syndrome or red man syndrome: rapid infusion of vancomycin or codeine.

Tophi- thiazides(from increased uric acid causing deposits in skin)

Hair: alopecia- steroids, male hormones (male pattern baldness), cancer chemotherapy
patches of hair growth: minoxidil, oral contraceptives

Nails-darkening: cancer chemotherapy
Oncholysis: tetracycline, doxorubicin, captopril

 

Eyes/vision
Exophthalmos and lid edema: steroids

Eyes:
dryness of eyes: anticholinergics, sympathomimetics

Cornea: corneal deposits from heavy metals such as gold and silver

Lens: deposits from use of phenothiazine.

Cataracts: steroids, drugs given to treat gallstones.

Glaucoma-primary-angle closure can be induced by atropine-like drugs; ibuprofen, Prolonged topical steroid therapy can increase intraoptical pressure.

Retinopathy: antimalarials, phenothiazines

Blurred vision: anticholinergics, certain antihistamines and certain antibiotics

Mydriasis (enlarged pupils): from atropine or other drugs given locally for purpose of causing mydriasis (as before eye exam) or as side effect of atropine or other drugs with atropine-like anticholinergic side effects.

Miois(pinpoint pupils): opioid drugs; exposure to drugs with cholinergic effects, e.g.. pilocarpine, bethanechol, neostygmine, physostigmine

Impairment of night vision: pilocarpine

Nystagmus: hydantoin (Dilantin)

Toxic ambylopia: digitalis preparations, high doses of nicotinic acid

Diplopia: acetophenazine, oral contraceptives

Color disturbances may occur as result of digitalis therapy (yellow scotomotor). Ethambutol may cause loss of green vision

 

Ear/Hearing
Drugs may affect either or both branches of the eighth cranial nerve(acoustic or vestibular), affecting hearing and/or vestibular function. Renal function is important to assess in a patient receiving an ototoxic drug that is excreted by the kidney.

Ototoxic drugs include aminoglycoside antibiotics (e.g. streptomycin, gentamycin, kanamycin); loop diuretics (e.g. furosemide, bumetanide, ethacrynic acid); vancomycin (even if only topical administration), chloroquine, quinine, quinidine, phenylbutazone

Assessment of drug effects on vestibular function can be assessed through Romberg's test or finger to nose Ataxia and imbalances are early signs of vestibular dysfunction. Check also for nystagmus. If the patient is taking antiemetics for any reason or a drug with an antiemetic side effects, this could interfere with the testing of vestibular function.

Vital Signs:
Blood pressure: orthostatic hypotension: antihypertensives, diuretics.

Increased blood pressure: drugs causing sodium and fluid retention

Beta blockers blunt or prevent the reflex tachycardia normally present on standing

Nose
Inflamed nasal membranes: cocaine use, neosynephrine, high levels of female sex hormones

Rhinitis medicamentosus: dry red nasal mucosa from abuse of decongestants

Mouth
Bleeding gums: anticoagulants

Blue-black gum margins: bismuth therapy

Overgrowth of gums (gingival hyperplasia) : hydantoin, excessive oral contraceptives

Dry mouth: anticholinergics or drugs with atropine-like/anticholinergic side effects(e.g. antihistamines, psychotropics)

Stomatitis: cancer chemotherapy

Monilia: anti-infective or immunosuppressive therapy

Hairy tongue: overgrowth of fungi from antibiotic therapy

Discoloration of teeth: tetracycline, liquid iron preparations

Taste: Metallic taste: oral hypoglycemics
garlic taste: DMSO
partial or total loss of taste: penicillamine
taste disturbances: lithium, certain TB drugs

Lymph nodes

generalized enlargement of lymph nodes can occur from mediastinal effects of hydantoins, PAS or phenylbutazone.

Breasts:
Gynecomastia: cimetidine, adrenocorticosteroids, androgens, cardiac glycosides, oral contraceptives. vincristine, reserpine, INH, phenothiazines, spironolactone, marijuana, antihypertensives, tranquilizers, antidepressants, amphetamines.
galactorrhea: psychotropic medications, oral contraceptives, morphine, heroin, metoclopramide,

Cardiac
Many drugs cause cardiac effects detectable by physical examination. Most of these are adverse effects of the drugs or extensions of their pharmacological effects- e.g.. slowing of heart rate from digitalis glycosides or beta adrenergic blockers.

Respiratory
Cough: ACE inhibitors

Beta blockers, especially those that are considered to be noncardiac selective, can produce wheezing and other indications of bronchial constriction.

Wheezing and other signs and symptoms of asthma: allergic response triggered by drug therapy

Abdomen
Epigastric distress can be a result of reflux of drugs from the stomach into the lower esophagus. This can occur as a result of swallowing a pill or tablet and lying down immediately. Patient should be taught not to lie down after taking drugs for at least half hour. Epigastric distress can also result from any drugs causing gastric irritation.

Nausea, vomiting and diarrhea: can be an indication of a reaction to almost any drug.

Bleeding from upper GI tract can be result of use of ASA, NSAIDs, steroid therapy, anticoagulant therapy.

Examination of the liver should be done routinely on all patients on oral contraceptive therapy because of the potential development of liver tumors.

Jaundice may be the result of drug-induced liver damage (e.g. INH, PAS, chlorpromazine) or cholestasis (e.g. Elavil, chloramphenicol thiazides, thorazine). Observe for scratching from pruritus caused by jaundice. It may be necessary to use a different type of lighting since fluorescent lighting will not reveal excessive bile pigmentation in the skin.

Bowel sounds:
decreased by anticholinergic drugs, opioid drugs, or any drug causing hypokalemia (e.g. thiazide or loop diuretics).
Hyperactive bowels sounds and diarrhea may be the results of superinfection from broad spectrum antibiotics.

Redness from scratching in the anal area may be due to pruritis ani caused by breakdown products of tetracyclines.

Kidney/Bladder
Hematuria: crystallization from sulfa drugs
Smoky bloody urine: may indicate low grade hematuria

Distended bladder- possible side effects of anticholinergic drugs ( constriction of urinary sphincter)
Extremities:

Edema-beta blockers, lithium

Neurological
Drug related cerebellar toxicity: e.g.. alcohol, phenytoin

Tardive dyskinesia: repetitive movement of oral/facial muscles- lip smacking, tongue movements (antipsychotic drugs)

Dystonias, akathesia extrapyramidal side effects, Parkinsonian syndrome: antipsychotics

Peripheral neuropathy: drug induced neuropathy usually expresses itself as palsies. paresthesia, or fasciculations.
Can be caused by many antibacterial and antitubercular agents, antidepressants such as MAO inhibitors and tricyclic antidepressants.

Decrease in Achilles tendon reflex may indicate the beginning of peripheral neuropathy
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