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

Genitals/Rectum
• Inspect the genitalia and perirectal area; note lesions, warts, etc.
• Culture discharges, ulcerative lesions, vesicles, and crusted lesions
for herpes simplex virus, chancroid, chlamydia, and/or gonorrhea
(GC), as appropriate, and send an RPR (rapid plasma reagin) or VDRL
(Venereal Disease Research Laboratory) test.
Female Patients
•
•
•
•
•
•
Speculum examination–note any lesions on vaginal walls or cervix.
Obtain a Papanicolaou smear. (Note: Abnormal or inconclusive
Papanicolaou smears require colposcopic follow-up, because
invasive cervical cancer may progress rapidly in women with HIV.
See chapter Cervical Dysplasia.)
Obtain endocervical swab for GC and chlamydia, and a posterior pool
swab for wet mount evaluation for trichomoniasis, Candida, and
bacterial vaginosis.
Bimanual exam–note size of uterus and ovaries, shape, and any
tenderness or pelvic pain.
Rectal examination for anorectal lesions, warts, etc, and evaluation
of uterine abnormalities.
Anal Papanicolaou smear.*
Male Patients
•
•
•
•
External genitalia–note whether male is circumcised; note any
lesions, discharge, other abnormalities, as above.
Testicular examination for masses, tenderness.
Rectal exam—digital examination to evaluate rectal tone,
discharge or tenderness, masses, lesions; prostate exam if
appropriate.
Anal Papanicolaou smear.*
* Anal Papanicolaou smear: Consider this test if follow-up
evaluation of abnormal Papanicolaou test results is available.
The suggested approach in HIV-infected women and men for
anal dysplasia screening is similar to the cervical Papanicolaou
screening guidelines for women: perform anal Papanicolaou
test at initial diagnosis and, if normal, repeat at 6 months. If the
first 2 anal Papanicolaou smears are normal, repeat annually.
If a Papanicolaou test shows ASCUS (atypical squamous cells
of undetermined significance) or SIL (squamous intraepithelial
lesion), refer for anal colposcopy and biopsy. (See chapter Anal
Dysplasia.)
Section 1—Testing and Assessment | 1–13
Extremities/ Musculoskeletal
•
•
•
•
•
•
Joints—note any enlargement, swelling, or tenderness.
Muscles—for the major muscle groups, pay close attention to
muscle bulk (normal or decreased), tenderness, or weakness.
Look for evidence of peripheral fat atrophy.
Consider measuring baseline arm, thigh, and chest circumferences
for later comparison.
Note nail changes (clubbing, cyanosis, fungal infections).
Assess for pedal or leg edema.
Habitus
• Subcutaneous fat loss (face, extremities, buttocks).
• Central fat accumulation (neck, dorsocervical, breasts, abdomen).
Neurologic
•
•
•
•
•
•
Mental status—including orientation, registration, recent and
remote memory, and ability to calculate (serial subtraction)
Cranial nerves
Peripheral sensory examination should include pinprick,
temperature, and vibratory stimuli.
Extremity strength and gait to discern myopathy, neuropathy, and
cerebellar disease
Fine motor skills such as rapid alternating movements (often
abnormal in dementia)
Deep tendon and plantar reflexes
Psychiatric
•
•
•
•
•
Patient’s general mood (depressed, anxious, hypertalkative, etc)
Verbal content–answers questions appropriately;
discussion of suicide
Inappropriate or unusual behavior, such as extremes of denial,
hostility, or compulsiveness
See Neuropsychiatric Disorders section for more complete
information on common pathologies.
Emergency situations, such as potential suicide or violence—
refer to crisis mental health services for immediate evaluation