Interim History and Physical Examination

Background

This chapter shows the suggested frequency and follow-up intervals of the history and physical examination for monitoring HIV-infected patients, as well as specific areas to assess in an ongoing manner. With this information, the clinician can track disease progression and formulate and maintain an appropriate care plan. Note that information gathered in the history or physical examination may indicate a need for additional directed explorations.

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.)

See chapter Initial and Interim Laboratory and Other Tests for recommended screening tests.

Table 1. History and Physical Examinations
HistoryPhysical Examination
Every visit (at least every 3-4 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
  • Antiretroviral (ARV) doses missed in the past 3 days, in the past month
  • Knowledge of HIV regimen
  • HIV transmission risk behaviors and risk reduction methods
  • Sexual history (risk factors for STDs)
  • Mood
  • Alcohol and recreational drug use
  • Tobacco use
  • Allergies
  • Pain
  • Social supports
  • Housing
  • Insurance
  • Intimate partner violence
  • Vital signs (temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation)
  • Weight
  • General appearance and body habitus (including evaluation for lipodystrophy)
  • Skin
  • Oropharynx
  • Lymph nodes
  • Heart and lungs
  • Abdomen
  • Neurologic
  • Psychiatric (e.g., mood, affect, and attention)
Every 6 months
As aboveAs above, plus:
  • Vision and funduscopic examination (if CD4 count <100 cells/µL)
  • Ears/nose
Every 6 months (twice), and, if both are normal, annually thereafter (see chapters Cervical Dysplasia and Anal Dysplasia)
As above
  • Women: pelvic examination; cervical Papanicolaou (Pap) test; consider anorectal examination, anal Pap test
  • Men: consider anal examination, anal Pap test
Annually
Update initial history: HIV-related symptoms, hospitalizations, major illnesses, and family historyComplete physical to include:
  • Genitorectal examination
  • Testicular examination
  • Prostate examination
  • Breast examination

References

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HRSA HAB Performance Measures

Abbreviations for Dosing Terminology

BID
twice daily
BIW
twice weekly
IM
intramuscular (injection), intramuscularly
IV
intravenous (injection), intravenously
PO
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
QAM
every morning
QD
once daily
QH
every hour
QHS
every night at bedtime
QID
four times daily
QOD
every other day
QPM
every evening
TID
three times daily
TIW
three times weekly