Clinical Guide > Testing and Assessment > Physical Exam

# Initial Physical Examination

January 2011

### Chapter Contents

      - Background 
      - S: SubjectiveO: ObjectiveA/P: Assessment and PlanPatient EducationReferencesTable 1. Vital SignsTable 2. Physical ExaminationHRSA HAB Core Clinical Performance MeasuresBackground 
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. 
S: Subjective
See chapter *Initial History*.
O: Objective
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 SignsVital SignRecommendation/Notes(These measurements establish a baseline against which future measurements can be compared.)HeightShould be measured once.WeightRecord at each visit.TempteratureRecord at each visit.Blood pressureRecord at each visit. The BP cuff size should be appropriate for the patient's arm circumference.Heart rateRecord at each visit.Respiratory rateRecord at each visit.Oxygen saturationRecord 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).

**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
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:**
**BMI:**<18.5 = underweight 18.5-24.9 = normal range 25-29.9 = overweight ≥30 = obese
Table 2. Physical ExaminationRegionRecommendation/Notes
* Anal Pap test: Consider this test if follow-up evaluation of an abnormal Pap test result is available. Rates of anal dysplasia and anal cancer are higher in HIV-infected women and men than in HIV-uninfected individuals; see chapter *Anal Dysplasia*.
General- State of nourishment, well or ill appearing
Eyes- 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.
Ears/Nose- Examine ear canals and tympanic membranes.
- Visualize nasal turbinates.
- Palpate frontal and maxillary facial sinuses.
Oral Cavity- 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.
Endocrine- Check thyroid for enlargement, tenderness, nodules, and asymmetry.
Lymph Nodes- 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
Lungs- 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).
Heart- Examine for jugular venous distention (JVD).
- Palpate for point of maximal impulse (PMI).
- Note rate and rhythm, heart sounds, murmurs, extra heart sounds.
Breasts- Palpate for breast masses in both men and women.
- Check for symmetry, nipple discharge, dimpling, and masses.
Abdomen- 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).
Female Patients- 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.
Male Patients- 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.
Habitus- 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).
Skin- 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
Psychiatric- 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.
Patient Education
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:
- HIV disease   - Disease course
  - Significance of CD4 cell count and HIV viral load
  - Possible treatment approaches
  - Disclosure (e.g., whom the patient may need to tell about HIV status, relevant legal requirements, approaches to disclosure)
- HIV transmission prevention and risk reduction for HIV-positive individuals (see chapter *Preventing HIV Transmission/Prevention with Positives*)   - Strategies to prevent transmission of HIV to uninfected partners and to prevent acquisition of sexually transmitted infections, hepatitis, and other infections
  - Safer-sex approaches, including the use of condoms or other latex barriers during sexual contacts
  - Safer use of recreational drugs
- Nutrition   - Maintaining a healthy weight
  - Nutritional support resources, if appropriate
  - Importance of including a nutritionist in medical care
- Mental health   - Stress reduction
  - Rest and exercise to enhance a healthy mental state
- Adherence   - Importance of keeping medical appointments
  - Need for adhering to any medication regimen and the consequences of missed HIV medication doses
References- 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 . January 10, 2011. 
**HRSA HAB Core Clinical Performance MeasuresPercentage of women with HIV infection who have a **Pap screening** in the measurement year (Group 2)**