Clinical Manual for Management of the HIV-Infected ... - myCME.com

Headache
Background
Headache may have many causes in HIV-infected
persons, particularly those with low CD4 counts.
Possible causes include infections (opportunistic and
other) and central nervous system malignancies, HIVrelated
systemic illnesses, and medication toxicity. In
addition, of course, headache may be caused by any of
the processes that cause headaches in HIV-uninfected
individuals. New or severe headache should be evaluated
carefully.
S: Subjective
The patient complains of a new type of headache.
Determine the following during the history:
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History of headaches or migraines
Characteristics of the headache (location, quality of
pain, timing, duration, etc)
Recent head trauma
Allergies
History of sinusitis
Fevers
Visual changes
Dizziness, vertigo, nausea
Mental status changes
Seizures
Focal or other neurologic symptoms (see chapter
Neurologic Symptoms)
New rashes or ulcerations
Other symptoms
Usual versus recent caffeine intake
New medications (eg, zidovudine)
Relief of headache by any medication
Unprotected sex, new sex partner
O: Objective
Section 5—Complaint-Specific Workups | 5–27
Perform a physical examination as follows:
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Check vital signs. Look for fever, orthostasis, and
hypertension.
Examine the head and neck for trauma, sinus
tenderness, and neck mobility; check lymph nodes.
Check the eyes, including funduscopic examination,
for lesions or papilledema.
Look for oral lesions, dental abscess, thrush, and
pharyngeal drainage.
Examine the lungs for abnormal sounds.
Check the skin, including palms and soles, for rashes
or lesions.
Perform a complete neurologic examination,
including mental status examination.
Review recent CD4 measurements, if available,
to determine the patient’s risk for opportunistic
illnesses as a cause of headache.
A: Assessment
A partial differential diagnosis includes the following:
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Cryptococcal meningitis
Neurosyphilis
Tuberculous meningitis; other meningitis
Progressive multifocal leukoencephalopathy (PML)
Toxoplasmic encephalitis
Cytomegalovirus (CMV) meningoencephalitis or
retinitis
Other encephalitis
Central nervous system lymphoma
Systemic infection
Sinusitis
Anemia
Fever
Depression, anxiety disorder
Medication adverse effect
Stress or tension headache