Exam Finding Supporting Opiate Withdrawal Diagnosis
Muscle spasms (tremor) is the exam finding that supports a diagnosis of opiate withdrawal in this patient.
Clinical Reasoning
Among the four options presented, only tremor/muscle spasms is a recognized feature of opioid withdrawal, while the other findings either contradict the diagnosis or are nonspecific.
Key Exam Findings in Opioid Withdrawal
The Clinical Opiate Withdrawal Scale (COWS), the validated assessment tool for opioid withdrawal, specifically includes tremor observation as a scored parameter, ranging from tremor that can be felt but not observed (1 point) to gross tremor or muscle twitching (4 points) 1. This patient's presentation is consistent with the acute withdrawal phase, which typically peaks at 48-72 hours after last use 2.
Autonomic and musculoskeletal manifestations of opioid withdrawal include:
- Tremors and muscle twitching 1, 3
- Increased muscle tone 1, 3
- Body aches and myalgias 3, 4
- Involuntary twitching and kicking movements 4
Why the Other Options Are Incorrect
Miosis (pupillary constriction) is the opposite of what occurs in opioid withdrawal. Opioid intoxication causes miosis, while withdrawal causes pupillary dilation (mydriasis) 1. The COWS specifically scores for dilated pupils, with 5 points given when pupils are so dilated that only the rim of the iris is visible 1.
Dry mucous membranes contradicts the expected findings in opioid withdrawal. Instead, patients exhibit excessive secretions including rhinorrhea (runny nose), lacrimation (tearing), and excessive perspiration 1, 3, 4. The COWS scores both runny nose/tearing and sweating as distinct parameters of withdrawal 1.
Tremor versus generic "muscle spasms": While the question uses the term "muscle spasms," this aligns with the tremor and muscle twitching described in validated withdrawal scales 1.
Supporting Clinical Context
This patient's presentation is entirely consistent with opioid withdrawal syndrome:
- Timing: Last heroin use "a few days ago" places her in the 48-72 hour peak withdrawal window 2, 5
- Vital signs: Tachycardia (HR 106) and hypertension (BP 167/92) reflect autonomic overactivity characteristic of withdrawal 3, 4
- Symptoms: Nausea, vomiting, and anxiety are cardinal features of the withdrawal syndrome 1, 3, 4
Clinical Pitfall to Avoid
Do not confuse the pupillary findings of intoxication versus withdrawal. Opioid intoxication produces the classic triad of miosis, respiratory depression, and decreased consciousness, while withdrawal produces the opposite autonomic state with mydriasis, tachycardia, hypertension, and hyperarousal 1, 3.