Larry William Chang, MD, MPH
- HPI: include date and method of diagnosis, known laboratory data including CD4 and viral load data, new complaints, fears, clinical stage of HIV disease by WHO criteria, date of infection if known, OIs and symptoms, functional status
- PMH: include prior TB or exposure, residence and travel, mental health, weight change
- Allergies: any medications, hypersensitivity to prior ARVs
- Meds: ARV history, use of traditional medicines and other medicines
- Vaccinations: child and adult
- Substance use: alcohol use, smoking, other substances of abuse
- Sexual history: condom use, HIV status of partners, STI history, practices
- Social: family/partner violence, HIV status of partner and children, social support, diet, exercise, education
- Family history: early CVD, diabetes, TB
- Women: menstrual history, contraception, infertility, pregnancy history, childbearing plans
- Review of Systems: STI syndromes, headache, fever, weight loss, nausea, vomiting, visual changes, abd pain, cough, hemopytsis, shortness of breath, anemia, diarrhea, dysphagia, odynophagia, night sweats, sores, rash, fatigue, appetite, neuropathy, pain, sexual problems, depression
- Vital signs, weight, height
- General: pallor, jaundice, cachexia
- Oropharynx: candidiasis, OHL, KS, aphthous ulcers, periodontal disease.
- Skin: KS, fungal, folliculitis, prurigo nodularis
- Body habitus: fat accumulation and/or lipoatrophy (neck, face, breasts, buttocks, abdomen, extremities)
- Lymphadenopathy: localized requires evaluation; generalized common in HIV+
- Neurologic: cognitive dysfunction, neuropathy, focal neurologic findings, dementia
- Syndromic examination for STIs: urethral discharge, genital ulcer, vaginal discharge, lower abdominal pain, scrotal swelling, inguinal bubo, and genital growths.
- Men: Include prostate/rectal, genital exam if possible.
- Women: Include pelvic/rectal, breast exam if possible.
- HIV serology: See HIV Diagnosis.
- CD4 count
- Creatinine (preferable for all cases, but required if to start TDF)
- ALT and/or AST (required if to start NVP)
- Hgb, WBC (required if to start AZT)
- If available, chemistry panel to include glucose, cholesterol, triglycerides.
- If unable to perform creatinine, ALT, or other essential laboratories, then specimen should be sent to nearest facility where test can be performed.
- RPR (repeat yearly)
- PAP smear (if unavailable, then visualization with acetic acid screening)
- If available, HBsAg
- Pregnancy testing in women of reproductive age
- Urinalysis for urine protein
- Additional considerations for baseline testing include need for sputum sampling and/or chest x-ray in patients with suspected TB.
- Consider sending sputums for examination for TB if any of these signs present: cough >2 weeks, close family member diagnosed with TB, weight loss, hemoptysis, painless swelling in neck or axillae, night sweats.
- Vaccinations: per national guidelines
- Ophthalmologic fundoscopy: If CD4 < 50 or with visual symptoms
- Cervical PAP smear in women (if unavailable, then visualization with acetic acid screening)
- Anthropomorphic measures: mid upper arm circumference (MUAC) and triceps skin-fold thickness
- Chest x-ray if clinically indicated
- Malaria prevention: Are insecticide-treated bednets being used?
- Clean water: Are water safety and hygiene measures being taken?
TB prevention: Consider INH prophylaxis to prevent TB in patients whom active TB has been excluded.
Cotrimoxazole prophylaxis: Does patient qualify?
- Counsel on adherence (see adherence section).
- Counsel and educate on risk reduction.
- Counsel on condom promotion and provision.
- Counsel on compliance with treatment.
- Counsel on contacting and treating partners.
- All counseling must be offered in a setting that ensures privacy and confidentiality.