Clinical Manual > Testing and Assessment > Initial Physical Examination

	CONTENTS
1	Testing/ Assessment
2	Health Maintenance
3	ARV Therapy
4	ARV Complications
5	Complaints
6	Diseases
7	Pain and Palliative
8	Neuropsychiatric
9	Populations
10	Resources

Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 1: Testing and Assessment

Initial Physical Examination
July 2006

Chapter Contents
Background
Subjective
Objective
Assessment and Plan
Patient Education
References
Table 1. Patient Information
Table 2. Vital Signs
Table 3. Physical Examination

Background

Many of the conditions that put immunocompromised patients at risk for disease can be detected early, by means of a thorough history and physical evaluation. This chapter presents essential aspects of the initial physical examination of the HIV-infected individual. (For essential aspects of the history to cover in an initial clinic intake visit, see chapter Initial History.)

S: Subjective

When an HIV-infected patient presents for an initial examination, document the patient's full name, date of birth, date of assessment, and any other information standard to your practice (Table 1).

Table 1. Patient Information

First Name:	Last Name:
Date of Birth: ____ / ____ / ______	Date of Assessment: ____ / ____ / ______

O: Objective

Assess the patient's general appearance, affect, demeanor in answering questions, body language, and other relevant characteristics such as vital signs (Table 2). Perform a physical examination (Table 3).

Table 2. Vital Signs

Vital Sign	Recommendation
Weight	Record at each visit.
Height	Should be measured once.
Temperature	Document at each visit.
Blood Pressure	Use BP cuff size appropriatefor the patient's arm circumference.
Heart Rate	Provide a baseline rate for later evaluation of anemia, dehydration, and other physical conditions.
Waist, Hip	Waist and hip circumference should be measured for comparison in case the patient later develops metabolic complications of ART. Abdominal circumference: >102 cm (39") in men = abdominal obesity >88 cm (35") in women = abdominal obesity Waist-hip ratios: >0.95 in men = increased risk of CHD >0.85 in women = increased risk of CHD
Body Mass Index (BMI)	BMI can be helpful in determining obesity, wasting, and ART-related weight gain. Perform at baseline and upon changes in weight.

Key to abbreviations: ART = antiretroviral therapy; BMI = body mass index; CHD = coronary heart disease.

Table 3. Physical Examination

Eyes

Visual acuity and visual fields by confrontation.
Tests of extraocular movements and pupillary size and reaction.
Funduscopic examination--with or without mydriatics; especially important if CD4 count is <100 cells/µL.
Note any retinal lesions, white or yellow retinal discoloration, infiltrates, or hemorrhages (could indicate cytomegalovirus retinitis, retinal necrosis, or ocular toxoplasmosis).
Referral to ophthalmologist for retinal examination every 6 months if the CD4 count is <100 cells/µL.
Refer immediately if the patient has retinal lesions or new visual disturbances.

Ears/Nose

Examine ear canals and tympanic membranes.
Visualize nasal turbinates.
Palpate frontal and maxillary facial sinuses.

Oral Cavity

Good lighting is essential.
Assess gingiva and teeth.
Assess mucosal surfaces (remove dentures, if present); note any lesions, discolorations, or skin abnormalities.
Have patient lift tongue to assess the posterior side.
Note whether tonsils are absent or present and any abnormality in tonsil size.
Pharynx--lesions, exudate?

Endocrine

Check thyroid for enlargement, tenderness, nodules, and asymmetry.

Lymph Nodes

Document site, size, and characteristic of each palpable node.

Node Sites

Posterior cervical chain
Anterior cervical chain
Submandibular
Submental
Supraclavicular
Axillary
Epitrochlear
Inguinal
Femoral

Characteristics

Size (2 dimensions, in millimeters)
Consistency (hard, fluctuant, soft)
Tenderness
Mobility
Definition (discrete, matted)
Symmetry

Skin

Examine the entire body, including scalp, axillae, palms, pubic and perianal areas, soles of feet.
Describe all lesions: size, borders, color, symmetry/asymmetry, distribution, raised/flat, induration, encrustation.
Note evidence of folliculitis, seborrheic dermatitis, psoriasis, Kaposi sarcoma, fungal infections, prurigo nodularis, etc.

Lungs

Auscultate and percuss.
Note any abnormal sounds including crackles or wheezes (signs of infections, asthma, congestive heart failure, etc).
Note any absence of air movement (pneumothorax, pleural effusion, etc).

Heart

Note rate and rhythm, heart sounds, murmurs, extra heart sounds.
Palpate for PMI (point of maximal impulse).
Examine for JVD (jugular venous distension).

Breasts

Palpate for breast masses in both men and women.
Check for symmetry, discharge, dimpling, and masses.

Abdomen

View--note distension, obesity, undernutrition, vascular prominence, petechiae.
Auscultate--note bowel sounds.
Percuss--record liver size.
Palpate--note hepatomegaly or splenomegaly; note any tenderness or rebound.

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.)

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

A: Assessment and Plan

After completing the initial history and physical examination:

Complete the patient's database with the information garnered through the history and physical examination.
Document a problem list, assessment, and plan for patient care.
Complete follow-up or laboratory studies suggested by the history and physical exam. (See chapter Initial and Interim Laboratory and Other Tests.)
Prescribe opportunistic infection (OI) prophylaxis as appropriate. (See chapter Opportunistic Infection Prophylaxis.)
Refer for dental, nutrition, social services, and mental health care as appropriate.
Refer for any additional specialty care identified in the history or physical exam.
Order any appropriate vaccinations. (See chapter Immunizations for HIV-Infected Adults and Adolescents.)
Make follow-up appointment with health care provider.
Answer the patient's questions.

Patient Education

A very important aspect of caring for HIV-infected individuals is educating patients about HIV infection, including goals of care and ways of achieving those goals.

Review the following with each patient:

HIV disease
- Transmission and progression
- Significance of CD4 count and HIV viral load
- Possible treatment approaches
- Disclosure--whom the patient may need to tell about HIV status; approaches to disclosure
HIV transmission prevention and risk reduction for HIV-positive individuals
- Safer-sex approaches, including the use of condoms/latex barriers during all sexual contacts
- Safer use of recreational drugs
Nutrition
- Maintaining a healthy weight
- Nutritional support resources, if appropriate
- Importance of including a nutritionist in medical care
Mental health
- Stress reduction
- Rest and exercise to enhance a healthy mental state
Adherence
- Importance of keeping medical appointments
- Need for adhering to any medication regimen and the consequences of missed HIV medication doses
- Return appointment

References

Aberg, Gallant, et al. Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2004 Sep 1;39(5):609-29. Available online at www.journals.uchicago.edu/CID/.

Bartlett JG, Cheever L. A Guide to Primary Care of People with HIV/AIDS, 2004 Edition. Rockville, MD: Department of Health and Human Services, HIV/AIDS Bureau. 2004. Available online at hab.hrsa.gov/tools/primarycareguide/.

Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/order.html.

Hollander H. Initiating Routine Care for the HIV-Infected Adult. In: Sande MA, Volberding PA, eds. The Medical Management of AIDS, 5th ed. Philadelphia: WB Saunders; 1997:107-112.

U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons--2002. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006.

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