Clinical Guide > Testing and Assessment > Interim History and Exam

# Interim History and Physical Examination

January 2011

### Chapter Contents

      - Background 
      - ReferencesTable 1. History and Physical ExaminationsHRSA HAB Core Clinical Performance MeasuresBackground 
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 ExaminationsHistoryPhysical ExaminationEvery 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 monthsAs 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
AnnuallyUpdate initial history: HIV-related symptoms, hospitalizations, major illnesses, family historyComplete physical to include: - Genitorectal examination
- Testicular examination
- Prostate examination
- Breast examination
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.
- Hecht F, Soloway B.  The physical exam in HIV infection . AIDS Clin Care. 1991:3(1):4-5.
- 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.
**HRSA HAB Core Clinical Performance MeasuresPercentage of clients with HIV infection who had **two or more medical visits in an HIV care setting** in the measurement year (Group 1) Percentage of women with HIV infection who have a **Pap screening** in the measurement year (Group 2) Percentage of clients with HIV infection who received **HIV risk counseling** within the measurement year (Group 2)**