Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
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5–38 | <strong>Clinical</strong> <strong>Manual</strong> <strong>for</strong> <strong>Management</strong> <strong>of</strong> <strong>the</strong> <strong>HIV</strong>-<strong>Infected</strong> Adult/2006<br />
O: Objective<br />
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Check vital signs (temperature, blood pressure, heart<br />
rate, and respiratory rate, oxygen saturation) and<br />
orthostatic measurements.<br />
Per<strong>for</strong>m a careful physical examination as guided by<br />
<strong>the</strong> history, with special attention to <strong>the</strong> following:<br />
General appearance: mood, affect, mannerisms<br />
Head and neck: signs <strong>of</strong> trauma, sinus tenderness,<br />
lymph node status, neck mobility<br />
Eyes, including fundi: lesions, papilledema<br />
Lungs, heart: abnormal sounds<br />
Extremities: muscle tone and bulk<br />
Skin, mucous membranes: rash, lesions<br />
Conduct a thorough neurologic examination,<br />
including cranial nerves, motor function, sensory<br />
function, coordination, gait, and deep tendon<br />
reflexes.<br />
Conduct a mental status examination.<br />
Review recent CD4 measurements, if available,<br />
to determine <strong>the</strong> patient's risk <strong>for</strong> opportunistic<br />
illnesses.<br />
A: Assessment<br />
The differential diagnosis <strong>of</strong> neurologic abnormalities in<br />
patients with <strong>HIV</strong> infection may be broad, particularly<br />
if <strong>the</strong> CD4 count is low. Both <strong>HIV</strong>-related and <strong>HIV</strong>unrelated<br />
causes should be considered; remember that<br />
more than one cause <strong>of</strong> symptoms may be present.<br />
Causes related to <strong>the</strong> cerebrum or cranial nerves<br />
♦ Toxoplasmic encephalitis<br />
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Primary CNS lymphoma<br />
Cryptococcal meningitis<br />
Cytomegalovirus (CMV) encephalitis<br />
O<strong>the</strong>r meningitis (bacterial, tuberculous, fungal,<br />
viral)<br />
Progressive multifocal leukoencephalopathy (PML)<br />
Neurosyphilis<br />
CNS coccidioidomycosis, histoplasmosis<br />
<strong>HIV</strong>-related dementia<br />
Alcohol or drug intoxication or withdrawal<br />
(medications or illicit drugs); chronic alcohol abuse<br />
Depression, mania, anxiety, psychosis<br />
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Cerebrovascular accident; stroke<br />
Metabolic abnormalities, including hypo- or<br />
hyperglycemia, electrolyte abnormalities<br />
Causes related to <strong>the</strong> spinal cord, nerve roots, peripheral nerves, and muscle<br />
♦ Inflammatory demyelinating polyneuropathy (eg,<br />
Guillain-Barré syndrome)<br />
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Polyradiculitis (eg, CMV, herpes simplex virus)<br />
Vitamin deficiency<br />
Myositis<br />
Myopathy (eg, due to zidovudine)<br />
Myelopathy (<strong>HIV</strong> vacuolar myelopathy)<br />
Epidural abscess or mass<br />
Mononeuritis multiplex<br />
Lactic acidosis<br />
Electrolyte abnormality (eg, hypokalemia)<br />
Peripheral neuropathy<br />
Distal sensory polyneuropathy<br />
Antiretroviral toxic neuropathy (especially stavudine,<br />
didanosine)<br />
O<strong>the</strong>r neuropathy (eg, due to diabetes, alcohol,<br />
medications [isoniazid, dapsone, many o<strong>the</strong>rs])<br />
Note that organic causes <strong>of</strong> neurologic symptoms must<br />
be ruled out be<strong>for</strong>e concluding that symptoms are<br />
psychiatric in nature.<br />
P: Plan<br />
Diagnostic Evaluation<br />
Unstable or seriously ill patients should be hospitalized<br />
<strong>for</strong> evaluation and treatment. Criteria <strong>for</strong> hospitalization<br />
include acutely altered mental status, fever with focal<br />
neurologic findings, and new or unstable seizures.<br />
Per<strong>for</strong>m laboratory work and o<strong>the</strong>r diagnostic studies<br />
as suggested by <strong>the</strong> history, physical examination, and<br />
differential diagnosis. This may include <strong>the</strong> following:<br />
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Establish <strong>the</strong> CD4 count (if not done recently)<br />
to help with risk stratification <strong>for</strong> opportunistic<br />
illnesses.<br />
Determine which laboratory tests are appropriate<br />
depending on <strong>the</strong> patient’s presentation. The initial<br />
evaluation <strong>of</strong>ten includes a <strong>com</strong>plete blood count<br />
with differential and monitoring <strong>of</strong> electrolyte and<br />
glucose levels.
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