Interim History and Physical Examination

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 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.

Table 1. History and Physical Examinations

Table 1. History and Physical 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 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 Every 6 months As above As above plus: Visual and funduscopic exam Ears/nose Screening for chlamydia, gonorrhea, and 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