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

Interim History and Physical Examination
Background
This chapter suggests information to gather and
document for a standard written record of clinically
important data over many visits. With this information,
the clinician can track disease progression and formulate
and maintain an appropriate care plan.
It is important to document new or ongoing symptoms
and functional limitations at each visit. This information
is particularly useful when outside agencies must
Table 1. History and Physical Examination: Frequency and Follow-Up Intervals
Section 1—Testing and Assessment | 1–21
determine the patient’s disability status. (See chapter
Karnofsky Performance Scale.)
Table 1 lists the suggested frequency and follow-up
intervals of the history and physical examination for
monitoring HIV-infected patients. Note that specific
medications and abnormalities may call for additional
directed examinations.
History Physical Examination
Every visit (at least every 3 months)
• New symptoms
• Medications
• HIV-related
medications
• Medications for other
conditions
• Over-the-counter
medications
• Herbs or vitamins
Every 6 months
• Adherence to
medications
and clinical care
visits
• Risk reduction;
prevention with
positives
•
•
•
•
•
Mood
Alcohol and
recreational
drug use
Tobacco use
Allergies
Pain
•
•
•
•
Social
supports
Housing
Insurance
Domestic
violence
•
•
•
•
Vital signs (temperature,
blood pressure, heart
rate, respiratory rate)
Weight
General appearance, body
habitus (including evaluation
for lipodystrophy)
Skin
•
•
•
•
•
•
Oropharynx
Lymph nodes
Heart and lungs
Abdomen
Psychiatric–
mood, affect
Neurologic
As above As above plus:
• Visual and
• Ears/nose
• Screening for chlamydia, gonorrhea, and
funduscopic exam
syphilis in all patients at risk for these infections
Every 6 months (twice) , and, if both are normal, annually thereafter (See chapters Cervical Dysplasia and Anal Dysplasia.)
As above • Women: cervical and anal
Papanicolaou smear, pelvic exam
• Men: anal Papanicolaou smear
Annually
Update initial history:
HIV-related symptoms, hospitalizations, major illnesses, family history
Complete physical to include:
•
•
Genitorectal exam
Prostate exam
• Breast exam
•
Testicular exam