Clinical Guide > Testing and Assessment > Interim History and Exam

Interim History and Physical Examination

January 2011

Chapter Contents

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 call 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.)

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
  • Risk reduction; prevention with positives
  • 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, oxygen saturation)
  • Weight
  • General appearance, body habitus (including evaluation for lipodystrophy)
  • Skin
  • Oropharynx
  • Lymph nodes
  • Heart and lungs
  • Abdomen
  • Neurologic
  • Psychiatric -- mood, affect
Every 6 months
As aboveAs above, plus:
  • Vision and funduscopic examination (if CD4 count <100 cells/µL)
  • Ears/nose
  • Screening for chlamydia, gonorrhea, and syphilis in all patients at risk of these infections
Every 6 months (twice), and, if both are normal, annually thereafter
(see chapters Cervical Dysplasia and Anal Dysplasia)
As above
  • Women: cervical Papanicolaou (Pap) test, pelvic examination; consider anal Pap test
  • Men: consider anal Pap test
Annually
Update initial history: HIV-related symptoms, hospitalizations, major illnesses, family historyComplete physical to include:
  • Genitorectal examination
  • Testicular examination
  • Prostate examination
  • Breast examination

References

HRSA HAB Core Clinical Performance Measures