BC Centre in HIV/AIDS Primary Care Guidelines

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1.2 Physical Examination

Schedule routine monitoring visits at least every 3 – 6 months for patients who are clinically stable and on ARV therapy. More frequent visits should be scheduled for those who are clinically unstable or not on ARV therapy. See also: 2.3 Monitoring

 Assess atComments
BP, Weight, Symptom Review Each visit  
Eyes Baseline and every 6 months thereafter while CD4 <50 cells/mm³ Perform or refer for a funduscopic examination when CD4 <50 cells/mm³
Head, Ears, Nose, Throat Baseline and at least annually
  • sinus infection
  • odynophagia
  • dysphagia
  • hearing loss
Oral Baseline and at least annually
  • oral candidiasis (thrush)
  • hairy leukoplakia (examine lateral borders of tongue)
  • Kaposi's sarcoma
  • gingival disease
  • aphthous ulcers
Pulmonary Baseline and at least annually
  • lung fields for wheezes
  • rhonchi
  • rales
  • dullness
Cardiovascular Baseline and at least annually
  • heart rhythm, heart murmur, click, or rub
  • peripheral pulses
  • evidence of peripheral vascular disease
  • peripheral edema
Abdominal Baseline and at least annually
  • hepatosplenomegaly
  • multiple lipomata in the subcutaneous fat
  • increased visceral fat
  • abdominal masses
  • tumours
Genitourinary Baseline and at least annually
Rectal Baseline and at least annually
  • visible anal lesions or evidence of skin abnormality around the anus
  • digital rectal exam
Musculoskeletal Baseline and at least annually
  • extremities, muscle wasting
  • joint inflammatory changes
Neuropsychological Baseline and at least annually
  • reflex, sensory, motor, and cerebellar function
  • signs of multifocal motor and sensory nerve abnormalities especially peripheral neuropathy
  • cranial nerves
  • cognitive status examination
  • mental health and substance use assessment
Skin Baseline and at least annually
  • rash and/or pruritus
  • psoriasis
  • molluscum contagiosum
  • seborrheic dermatitis
  • maceration of the gluteal cleft
  • Kaposi's sarcoma
  • onychomycosis
  • diffuse folliculitis with pruritus
  • melanoma
  • medication-related rash
Lymph Nodes Baseline and at least annually
  • particular attention to axillary, posterior cervical chain, supraclavicular, submental, axillary, epitrochlear, femoral
  • significant abnormalities may present as clusters of large nodes, asymmetry, tenderness, or sudden increase in size or firmness of nodes
Endocrine Baseline and at least annually
  • abnormal subcutaneous fat redistribution
  • thyroid gland assessment
Adapted from: Primary Care Approach to the HIV-Infected Patient. Office of the Medical Director, New York State Department of Health AIDS Institute. March 2007.

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