Best Next Step: Bedside Glucose Testing
In this stable 29-year-old woman with alcohol intoxication presenting with slurred speech and drowsiness, the best next step is bedside glucose testing (not listed but essential), followed by clinical observation—not routine urine drug screen, liver function tests, TSH, or head CT.
Clinical Assessment Framework
Why Routine Testing is Not Indicated
The American College of Emergency Physicians clearly states that in alert, cooperative patients with normal vital signs and a noncontributory history and physical examination, routine laboratory testing is of very low yield 1. This patient meets these criteria—she is hemodynamically stable with an obvious explanation (alcohol intoxication) for her presentation.
Urine drug screening (Option A) does not affect management in this clinical scenario. The ACEP guidelines specifically address this: results of urine drug screens have minimal impact on clinical management decisions in alert, cooperative patients with normal vitals and psychiatric symptoms 1. Research confirms that qualitative urine drug screens provide limited additional information compared to history taking in psychiatric emergency settings 2. Her reported marijuana cravings do not change acute management, and cannabis detection (which can persist for weeks) would not alter the current clinical approach 1, 3.
Liver function tests (Option B) are not indicated acutely. While chronic alcohol use can cause hepatic dysfunction, LFTs do not guide emergency management of acute intoxication in a stable patient 1. These tests are appropriate for outpatient follow-up or if there were signs of hepatic decompensation (jaundice, ascites, coagulopathy)—none of which are present 4.
TSH testing (Option C) is not appropriate in this acute setting. Although thyroid dysfunction can contribute to mood disorders in alcohol-dependent individuals, thyroid testing does not address the immediate presentation and would not change acute management 4. This is an outpatient workup consideration, not an emergency department priority.
Head CT (Option D) is not indicated. Neuroimaging is reserved for patients with focal neurological deficits, altered mental status beyond what is expected from intoxication, head trauma, or concern for structural lesions 1. This patient's drowsiness and slurred speech are entirely consistent with alcohol intoxication in someone who "smells of alcohol."
The Critical Exception: Bedside Glucose
Bedside glucose testing is mandatory and should be performed immediately 5. The American College of Emergency Physicians emphasizes that hypoglycemia is the most frequently missed abnormality in patients presenting with altered mental status, occurring in 1-2 cases per 136-163 patients 5. This takes seconds, costs virtually nothing, and can identify a life-threatening condition that mimics intoxication.
Appropriate Management Algorithm
- Immediate bedside glucose to exclude hypoglycemia 5
- Clinical observation until the patient returns to baseline neurologic status 1
- Reassessment to ensure symptoms resolve as expected with alcohol metabolism
- Consider additional workup only if:
- Symptoms persist beyond expected timeframe for alcohol clearance
- New symptoms develop
- Vital signs become abnormal
- Neurological examination reveals unexpected findings 1
Common Pitfalls to Avoid
Do not order reflexive "medical clearance" panels. The term "medical clearance" is problematic because it implies different things to different providers and leads to unnecessary testing 1. A focused medical assessment is superior to routine laboratory panels in stable patients with obvious intoxication.
Do not let elevated alcohol levels delay psychiatric evaluation. ACEP guidelines confirm that an elevated alcohol level does not preclude initiating psychiatric evaluation in alert, cooperative patients with normal vital signs 1. However, the patient must be cooperative and at baseline cognition—this patient's drowsiness may require waiting until she is more alert.
Do not dismiss the need for substance use disorder treatment. While acute testing is not indicated, this presentation in a patient with known alcohol use disorder and depression warrants outpatient referral for addiction treatment and mental health services 1.
Answer: None of the Listed Options
The correct answer among the choices provided would be none of the above—bedside glucose is the only test needed acutely. If forced to choose from the options given, all four (A, B, C, D) are incorrect for this stable patient with obvious alcohol intoxication. The best management is clinical observation after confirming normal glucose 1, 5.