Initial Physical Examination

Waist and hip circumference should be measured for comparison in case the patient later develops obesity or lipoaccumulation related to antiretroviral therapy (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 coronary heart disease (CHD)
>0.85 in women = increased risk of CHD

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:
<18.5 = underweight
18.5-24.9 = normal range
25-29.9 = overweight
≥30 = obese

• 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.
• Examine:
  • 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
  • Submandibular
  • Supraclavicular
  • Submental
  • Axillary
  • Epitrochlear
  • Inguinal
  • Femoral
• Characteristics:
  • Size (two dimensions, in millimeters)
  • Consistency (hard, fluctuant, soft)
  • Tenderness
  • Mobility
  • Definition (discrete, matted)
  • Symmetry

• 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.

• 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.

• 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.

• 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.