Initial Physical Examination
Guide for HIV/AIDS Clinical Care, HRSA HIV/AIDS Bureau
A/P: Assessment and Plan
Table 1. Vital Signs
Table 2. Physical Examination
Many of the conditions that put immunocompromised patients at risk of disease can be detected early, by means of a thorough history and physical evaluation.
See chapter Initial History.
Assess the patient's general appearance, affect, demeanor in answering questions, body language, and other relevant characteristics. Measure vital signs; perform a physical examination.
Table 1. Vital Signs
|(These measurements establish a baseline against which future measurements can be compared.)|
|Height||Should be measured once.|
|Weight||Record at each visit.|
|Tempterature||Record at each visit.|
|Blood pressure||Record at each visit. The BP cuff size should be appropriate for the patient's arm circumference.|
|Heart rate||Record at each visit.|
|Respiratory rate||Record at each visit.|
|Oxygen saturation||Record at each visit.|
|Waist, hip circumferences|
Waist and hip circumference should be measured for comparison in case the patient later develops obesity or lipoaccumulation related to antiretroviral therapy (ART).
>102 cm (39") in men = abdominal obesity
>88 cm (35") in women = abdominal obesity
>0.95 in men = increased risk of coronary heart disease (CHD)
>0.85 in women = increased risk of CHD
|Body mass index (BMI)|
BMI can be helpful in assessing underweight or overweight conditions, HIV/AIDS-related weight loss, and ART-related weight gain. Perform at baseline and upon changes in weight.BMI calculation:
<18.5 = underweight
18.5-24.9 = normal range
25-29.9 = overweight
≥30 = obese
Table 2. Physical Examination
- State of nourishment, well or ill appearing
- Examine visual acuity by Snellen chart, visual fields by confrontation.
- Test extraocular movements and pupillary size and reactivity.
- Perform funduscopic examination, with or without mydriatics. 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 <50 cells/µL.
- Refer immediately if the patient has retinal lesions or new visual disturbances.
- Examine ear canals and tympanic membranes.
- Visualize nasal turbinates.
- Palpate frontal and maxillary facial sinuses.
- Good lighting is essential for this examination.
- Gingiva and teeth (note loss of teeth, decay, inflammation)
- Mucosal surfaces (with dentures removed) (note any lesions or discolorations)
- Posterior tongue
- Tonsils (note absence or presence; any abnormality in tonsil size)
- Pharynx (note lesions, exudate)
- Refer to oral health specialist for examination.
- Check thyroid for enlargement, tenderness, nodules, and asymmetry.
- Document site and characteristics of each palpable node.
- Node Sites:
- Posterior cervical chain
- Anterior cervical chain
- Size (two dimensions, in millimeters)
- Consistency (hard, fluctuant, soft)
- Definition (discrete, matted)
- Inspect, auscultate, and percuss.
- Note any abnormal sounds including crackles or wheezes (e.g., signs of infections, asthma, congestive heart failure).
- Note any absence of air movement (e.g., pneumothorax, pleural effusion).
- Examine for jugular venous distention (JVD).
- Palpate for point of maximal impulse (PMI).
- Note rate and rhythm, heart sounds, murmurs, extra heart sounds.
- Palpate for breast masses in both men and women.
- Check for symmetry, nipple discharge, dimpling, and masses.
- View: examine for distention, obesity, undernutrition, vascular prominence, petechiae.
- Auscultate; note bowel sounds.
- Percuss; record liver size.
- Palpate for hepatomegaly, splenomegaly, masses, tenderness or rebound tenderness.
|Genitals / Rectum|
- Inspect the genitalia and perirectal area; note lesions, warts, etc.
- Look for discharges, ulcerative lesions, vesicles, or crusted lesions; take samples for diagnostic studies (e.g., for chlamydia, gonorrhea, herpes simplex virus, syphilis, chancroid, as appropriate).
- Perform speculum examination; note any lesions on vaginal walls or cervix.
- Obtain a Papanicolaou (Pap) test.
- Obtain endocervical swab for gonorrhea and chlamydia, and a posterior pool swab for wet mount evaluation for trichomoniasis, candidiasis, and bacterial vaginosis.
- Consider anal Pap test, especially if the patient has a history of an abnormal cervical Pap test or genital warts (perform before introduction of lubricant).*
- Bimanual examination; note size of uterus and ovaries, shape, and any tenderness or pelvic pain.
- Rectal examination (e.g., for anorectal lesions, warts) and evaluation of posterior uterine abnormalities.
- Examine external genitalia; note whether patient is circumcised; note any lesions, discharge, or other abnormalities, as above. Perform testicular examination for masses, tenderness.
- Consider anal Pap test (perform before introduction of lubricant).*
- Digital rectal examination to evaluate rectal tone, discharge or tenderness, masses, or lesions; perform prostate examination if appropriate.
|Extremities / Musculoskeletal|
- Joints; note any enlargement, swelling, or tenderness.
- Muscles; for the major muscle groups, evaluate 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, thickening, discoloration).
- Assess for pedal or leg edema.
- Look carefully for signs of lipoatrophy or lipohypertrophy, wasting, or obesity.
- Subcutaneous fat loss (face, extremities, buttocks).
- Central fat accumulation (neck, dorsocervical area, breasts, abdomen).
- Examine the entire body, including scalp, axillae, palms, soles of feet, and pubic and perianal areas.
- Describe all lesions (e.g., size, borders, color, symmetry/asymmetry, distribution, raised/flat, induration, and encrustation).
- Note evidence of folliculitis, seborrheic dermatitis, psoriasis, Kaposi sarcoma, fungal infections, prurigo nodularis, etc.
- Note any tattoos and or body piercings.
|Neurologic|| Assess the following: |
- Mental status, including orientation, registration, recent and remote memory, and ability to calculate (serial subtraction)
- Cranial nerves
- Peripheral sensory examination, including 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
- Assess the patient's general mood (e.g., depressed, anxious, hypertalkative).
- Note verbal content (e.g., whether the patient answers questions appropriately; unusual or odd content).
- Note inappropriate or unusual behavior, such as extremes of denial, hostility, or compulsiveness.
- See section Neuropsychiatric Disorders for more complete information on common pathologies.
- If the possibility of an emergency situation exists (e.g., potential suicide or violence), refer to crisis mental health services for immediate evaluation.
A/P: Assessment and Plan
After completing the initial history and physical examination, do the following:
- Enter the information garnered through the history and physical examination into the patient's chart or database.
- Continue to develop the problem list, assessment, and plan for patient care.
- Complete follow-up or laboratory studies suggested by the history and physical examination. (See chapter Initial and Interim Laboratory and Other Tests.)
- Prescribe opportunistic infection prophylaxis as appropriate. (See chapter Opportunistic Infection Prophylaxis.)
- Arrange for any appropriate vaccinations. (See chapter Immunizations for HIV-Infected Adults and Adolescents.)
- Refer for dental, nutrition, and social services, as well as case management and mental health care, as appropriate.
- Refer for any additional specialty care needs identified in the history or physical examination.
- Make follow-up appointment with health care provider.
- Answer the patient's questions.
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:
- Aberg JA, Kaplan JE, Libman H, et al.; HIV Medicine Association of the Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009 Sep 1;49(5):651-81.
- Hollander H. Initiating Routine Care for the HIV-Infected Adult. In: Sande MA, Volberding PA, eds. The Medical Management of AIDS, 5th Edition. Philadelphia: WB Saunders; 1997:107-112.
- Kaplan JE, Benson C, Holmes KH, et al; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009 Apr 10;58(RR-4):1-207.
- U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. March 27, 2012.