The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical Symptoms• Define the etiology and pathophysiology of each symptom• Clarify the nature of the underlying disease26 • picas Develop an understanding of the impact of both the disease process andsymptoms on quality of lifeThe assessment process can be conceptualized in the following steps:• Evaluation of the patient’s medical history• Physical examination• Investigations and further evaluationThese steps should allow for the development of a problem list and a treatment plan. The lattershould always include a method for ongoing evaluation of the impact of the treatment plan – aclearly defined plan for ongoing symptom assessment. A discussion of the detail of the manyspecific treatment plans that exist for each symptom is beyond the scope of this chapter, butthese issues are addressed in symptom-specific chapters. (See, e.g., Chapter 4: Pain, Chapter 6:Pulmonary Symptoms, and Chapter 8: Oral Problems.)Evaluation of Medical HistoryThe initial step in the assessment of the symptomatic patient involves the clinician elicitinga complete medical history. This process lies at the core of clinical diagnostic medicine. Symptomsmust always be considered in context of the overall medical condition.The order and timing that are chosen by the clinician for eliciting a patient’s medical historywill be influenced by a number of factors, including the following:• The degree of acute patient distress that is present• Convenience and efficiency• The previous relationship of the patient and clinicianClearly if a patient is in a great deal of distress an expedited history may be required while theclinician concurrently treats the patient’s acute distress (for example in the case of a patient insevere acute pain). Although distress that is so severe as to be in need of treatment withinminutes requires an expedited approach, this does not obviate the need for eliciting a detailedhistory from the patient or another source at a slightly later time.If the clinician is familiar with the patient, the clinician may already be aware of much of thehistory and the historytaking can be expedited. A clinician seeing a patient for the first time inan emergency setting will likely need to either spend more time with the patient or reviewavailable records to ascertain key components of the history.Approaches to HistorytakingWith complicated HIV-related illness and in cases where multiple symptoms are present, it canhelpful to deviate slightly from the traditional approach to historytaking by specifically elicitingthe symptom history, separate from the history of HIV infection and the known intercurrentillnesses. This approach can focus the history and help the clinician define both the detail of themedical problems and the detail of the distress. This approach also serves to emphasize the keycomponents of a palliative symptom assessment and, although it does depart slightly from thetraditional approach to historytaking, it does include all of the components of a traditionalhistory.48U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau