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	Providers' Home > Clinical Manual > Testing and Assessment > Article	Enlarge Text Size:

Testing and Assessment

Initial Physical Examination

July 2006

Contents

Background

SOAP (Subjective, Objective, Assessment, 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.)

SOAP (Subjective, Objective, Assessment, Plan)

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

Table 1. Patient Information
First Name:	Last Name:
Date of Birth: ____ / ____ / ______	Date of Assessment: ____ / ____ / ______

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.

Vital Signs

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

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

Key teaching points

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

	The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked Web sites, or the information, products or services contained therein.

	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.

Source: Clinical Manual for Management of the HIV-Infected Adult, AIDS Education and Training Centers


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Table of Contents

1: Tests / Assess

2: Health Maintenance

7: Pain and Palliative

Reviewed/Updated Date: August 31, 2008