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

8–18 | Clinical Manual for Management of the HIV-Infected Adult/2006
O: Objective
Perform the following tests:
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Check temperature and other vital signs, and
perform a thorough physical examination to
determine potentially reversible causes such as
opportunistic infections.
Perform a thorough neurologic examination,
including funduscopic exam. Check symmetry
of brow wrinkling, eyelid closure, and pupil size.
Perform Romberg and other tests to rule out focal
neurologic deficits.
Check gait by asking the patient to walk rapidly,
turn, and stop. Ask the patient to walk on heels and
tiptoes. Test steadiness of gait with eyes open and
closed. Ask the patient to stand from a squatting
position without assistance.
Perform a complete minimental status examination.
As a quick screen, ask the patient to write his or her
name, date, and location; to spell "world" backwards;
to perform memory-object recall of 3 objects after 5
minutes; and to make change from a dollar.
A: Assessment
Partial Differential Diagnosis
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Other CNS conditions, such as toxoplasmosis,
fungal infection, Mycobacterium avium complex
(MAC), lymphoma, cytomegalovirus ventriculitis
or encephalitis, normal-pressure hydrocephalus,
neurosyphilis, tuberculosis, or Cryptococcus
neoformans. Many of these are treatable.
Depression, which can present as cognitive
impairment.
Other medical causes, such as nutritional deficiencies
(eg, vitamin B12), metabolic disorders (eg,
hypothyroidism), toxins (eg, chronic alcohol use), or
infections (eg, tertiary syphilis)
Delirium, which is an acute manifestation of
cognitive impairment with inability to maintain
attention. Delirium can be due to many medical
conditions, but is also commonly caused by
medications, including those with anticholinergic
adverse effects, such as amitriptyline (Elavil),
promethazine (Phenergan), prochlorperazine
(Compazine), and diphenhydramine (Benadryl). An
anticholinergic delirium is characterized by visual
or tactile hallucinations, confusion, and sometimes
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agitation. Other medications that may cause
delirium include prednisone, meperidine (Demerol),
lithium (at toxic levels, which may occur in a stable
patient with a serious opportunistic infection
or dehydration), agonist-antagonist analgesics
such as pentazocine (Talwin), and short-acting
benzodiazepines such as midazolam (Versed) and
triazolam (Halcion).
Intoxication or withdrawal.
Mild Manifestations: HIV-Associated Minor Cognitive
Motor Disorder
At least 2 of the following symptom should be present:
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Impaired attention, concentration, or memory
Mental and psychomotor slowing
Personality changes
Rule out other causes.
Severe Manifestations: HIV-Associated Dementia
Signs will include the following:
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Acquired cognitive abnormality in 2 or more
domains, causing functional impairment
Acquired abnormality in motor performance or
behavior
No clouding of consciousness or other confounding
cause (eg, CNS infections, psychopathology, drug
abuse)
Table 1 describes the states of HAD.
Table 1. Stages and Characteristics of HIV-Associated
Dementia
Stage Characteristics
Stage 0 (normal) Normal mental and motor function
Stage 0.5 (subclinical) Equivocal symptoms of cognitive or motor
dysfunction; no impairment of work or
activities of daily living (ADL)
Stage 1 (mild) Evidence of intellectual or motor
impairment, but able to perform most ADL
Stage 2 (moderate) Unable to work, but can manage self-care
Stage 3 (severe) Major intellectual incapacity or motor
disability
Stage 4 (end-stage) Nearly vegetative
Source: Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns
Hopkins University Division of Infectious Diseases; 2005. Available online at http://hopkins-aids.
edu/mmhiv/order.html.