HIV CLINIC HISTORY AND PHYSICAL- initial encounter

HX OF PRESENT ILLNESS: (age, race, gender, AIDS vs HIV, year of HIV diagnosis, HIV risk factor, hx of OI’s, current complaints)

PMH/PSH:

MEDS: especially hx of prior anti-retroviral use, duration of anti-retroviral use and reason for discontinuation (i.e., disease progression, compliance, drug rxn)

ALLERGIES: especially Sulfa meds, ARV’s (abacavir, nevirapine)

SOCIAL HX: employment, living situation, marriage status, children, literacy and education

VICES:  tobacco, alcohol, drugs and route of use

TB exposure: PPD/anergy status, date and place of test, TB exposures, homelessness, jail/prison

SEXUAL PRACTICES AND STD’s:  herpes, GC, syphilis, meds and dates of treatments; current sexual practices (receptive vs insertive, oral/anal/vaginal, # partners, partners knowledge of pt’s HIV status, condom use, birth control use)

GYN:  duration of menses and time between menses, pregnancies/abortions/miscarriages/living children, last PAP and result, birth control (OCP, IUD, male +/or female condom)

PHYSICAL EXAM:

GENERAL: weight loss, fever (AIDS-related wasting, MAC, TB, lymphoma,etc.)

FUNDOSCOPIC EXAM:  yellow-white retinal infiltrates (CMV or toxoplasma retinitis)

ORAL:  white plaques (candidiasis), white lesions on lateral aspects of tongue (OHL), oral ulcers (HSV, CMV, apthous ulcers), violaceous macule or papule (KS, bacillary angiomatosis)

LYMPH NODES:  lymphadenopathy (PGL, lymphoma, TB, syphilis)

ABDOMINAL:  hepatosplenomegaly (MAC, TB, lymphoma, histoplasmosis)

PERIRECTAL ULCER:  HSV, CMV

GENITAL: genital sores (syphilis, HSV, chancroid, condyloma acuminata, molluscum contagiosum)

NEUROLOGIC:  motor deficits (CNS toxoplasmosis, lymphoma, neurosyphilis, TB, PML, AIDS-related neuropathy), sensory deficits (neuropathies0, neurocognitive functioning (dementia)

SKIN:  violaceous papule or macule (KS, BA), scaling lesions (seborrheic dermatitis, fungal infection, psoriasis), papular eruption (Staphylococcus aureus folliculitis, scabies, molluscum contagiosum (esp. in the pubic area), EPF), purpura (AIDS-related ITP), vesicular rash (zoster, HSV, drug rxn)

ASSESSMENT/PLAN:

HIV DISEASE:  discussion of viral load testing, anti-retroviral options/strategies, plan and goals of therapy, set-points for changing therapy, importance of compliance and adherence to ante-retroviral regimen

HIV TRANSMISSION:  routes of transmission (sex, needle-sharing), methods to prevent spread of virus (abstinence, latex condoms, needle-exchange programs); Rx’s:  condoms if patient is sexually active

PROPHYLAXIS:  PCP proph if CD4<200, OI’s, or thrush;  gradual initiation of TMP-SMX; MAC proph if CD4 <50

TB PROPHYLAXIS:  PPD +/- anergy panel (if none done in last 6 months), INH/B6 prophylaxis for hx of significant exposure 

GYN:  PAP/pelvic if not done in last 6-12 months, STD screening, birth control, colposcopy referral for CIN

VACCINATION: pneumovax (every 5 years), influenza (seasonal), hepatitis B vax if needed

COMMON LABS:
CD4, Chem20, CBC, RPR,, CMV IgG, Hepatitis B Surface Ag/Ab/Core ab, Hepatitis C ab
Labs to consider where appropriate:
HIV VL, TOXOPLAMSOSIS IgG , Serum Cryptococcal Ag
Helpful info:
A CD4+ T-cell count <200 cells/µl (or a CD4+ T-cell % of total lymphocytes of <14%) or one of the following defining illnesses:
Candidiasis of bronchi, trachea, or lungs 
Candidiasis esophageal 
Cervical cancer (invasive) 
Coccidioidomycosis, disseminated or extrapulmonary 
Cryptococcosis, extrapulmonary 
Cryptosporidiosis, chronic intestinal for longer than 1 month 
Cytomegalovirus disease (other than liver, spleen or lymph nodes 
Encephalopathy (HIV-related) 
Herpes simplex: chronic ulcer(s) (for more than 1 month); or bronchitis, pneumonitis, or esophagitis 
Histoplasmosis, disseminated or extrapulmonary 
Isosporiasis, chronic intestinal (for more than 1 month) 
Kaposi's sarcoma 
Lymphoma Burkitt's, immunoblastic or primary brain 
Mycobacterium avium complex 
Mycobacterium, other species, disseminated or extrapulmonary 
Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii) 
Pneumonia (recurrent) 
Progressive multifocal leukoencephalopathy 
Salmonella septicemia (recurrent) 
Toxoplasmosis of the brain 
Tuberculosis 
Wasting syndrome due to HIV