IV. This text will provide you with information necessary for

a doctor to render primary care. Pay attention to the way it is organized into paragraphs. The headings will help you to refer to details quickly if necessary. Now look at these questions and read the text through to find the answers.

1. What should the doctor know caring HIV-infected patient?

2. What questions should the doctor ask to evaluate patient's condi­tions?

3. What organ systems is it necessary to examine to provide docu­mented detailed physical examination? primary care for hiv infection Part I

Because the first patients infected by what we know as human immunodeficiency virus presented with previously rare opportunistic infections and malignancies, they were cared for by specialists in infec­tious disease or hematology and oncology. Such specialists remain essen­tial in helping diagnose and manage the complications of advanced HIV disease.

The physician caring for patients with early HIV infection should know which elements of the history and physical examination hold par­ticular importance, know what diagnostic studies are necessary, know when and how to begin antiretroviral therapy (as well as prophylaxis against Pneumo-cystic carinii pneumonia), know what other preventive measures should be offered, and be able to provide appropriate counsel­ing. It must be said that diagnostic and therapeutic recommendations change frequently as new treatments are developed as the results of ongo­ing studies become available. The recommendations to be offered in this article are up-to-date, but they will surely be evolving.

Initial Evaluation

Data derived from the history, physical examination, and certain diagnostic studies identify the stage of HIV infection and determine the appropriate treatment. Many staging systems have been suggested. A problem with all of them is that significant clinical variation is seen with­in any one stage. It may be more useful simply to describe patients as hav­ing asymptomatic, symptomatic, or advanced HIV disease - with advan­ced disease usually manifest by an AIDS-defining diagnosis such as P. carinii pneumonia or Mycobacterium avium infection. At present, the ini­tiation of antiretroviral treatment and Pneumocystic prophylaxis is guid­ed by the CD4 count and not by clinical status.

The history

Estimating the date of initial HIV infection helps predict the likely timing of disease progression. The task is easiest when there has been a known blood exposure, but even in other cases, the patient may have experienced a limited number of high-risk sexual or drug-use exposures - or perhaps only one such exposure. Knowing the likely time and route of infection also helps the clinician understand the social context in which the illness is occurring.

The clinician should ask the patient about prior sexually transmitted diseases (which may require ongoing treatment) and about prior infection with hepatitis В virus. A history of multiple episodes of sexually trans­mitted disease or viral infections (as well as bacterial pneumonia, parasitic infections or gastroenteritis) indicates significant immune-suppression.

The use of drugs and alcohol should be discussed openly. Additional high-risk behavior (such as unsafe sex or needle sharing) and behavior that interferes with medical care (missed appointments or noncompliance with therapeutic regimens) should be addressed as well.

The review of systems should be directed at signs and symptoms asso­ciated with HIV disease. These include constitutional symptoms, such as weight loss, fever, night sweats, fatigue, and pain, and specific symp­toms, including lymphadenopathy, rashes, oral lesions, headaches, decreased vision, cough, dyspnea, abdominal pain, diarrhea, recurrent vaginal discharge, abnormal bleeding, or difficulty with memory or con­centration.

Physical examination

HIV can affect any organ system. Thus, a detailed physical examina­tion is essential, with careful documentation of baseline observations to make early recognition of new problems easier. Baseline pulmonary and cardiovascular examinations are important because of the high frequency of pulmonary infections and cardiac complications in advanced HIV dis­ease. Since hepatic or splenic enlargement marks numerous complications of advanced disease, the baseline size of these organs should be noted, too. Weight loss can be a sign of disease progression. Conversely, weight gain may occur in response to successful therapy. Thus the patient's weight should be recorded along with the vital signs at each visit.

The first manifestations of clinical HIV disease are often seen in the skin or the oral cavity. Common oropharyngeal lesions include herpetic ulcers or vesicles, candidiasis exudates, diffuse erythema (which can occur in candidiasis, herpes simplex infections, or bacterial periodontitis), and hairy leukoplakia (which most often produces plaques on the side of the tongue). Nodules are less common. They should be biopsied promptly, since they may represent Kaposi sarcoma or lymphoma.

The development of oral candidiasis is a sign of worsening immune function and may thus have special prognostic significance. Moreover, the coincidence of esophageal candidiasis with oral thrush is very high. (It approaches 100% in some studies.) Patients with a history of oral can­didiasis who complain of odynophagia should be treated empirically with a systemic antifungal agent such as fluconazole, and those who do not readily respond should undergo upper gastrointestinal endoscopy to eval­uate other causes of their complaint, including infection by cytomegalo­virus or herpes simplex virus.

The major lymph groups should be examined on each visit. The size, texture, and tenderness of the nodes should be noted, along with the pre­dominance of any one group. Persistent lymphadenopathy may be the only sign HIV disease. Nodes do not require biopsy unless they are rapidly enlarging or are associated with fever and weight loss, as may be seen in lymphoma or extrapulmonary mycobacterial disease.

The genitalia should be examined for ulcerative or vesicular lesions and for condylomata. In men, induration and swelling of the epididymis may represent gonococcal, chlamydial, or (rarely) mycobacterial infec­tions. Women should be examined for signs of cervicitis, and Pap smears should be obtained at six-month intervals. Rectal lesions are common in patients who have had receptive anal intercourse. The anus and rectum should be examined for. signs of sexually transmitted disease (including condylomata, syphilitic chancres, and herpetic vesicles or ulcerations), as well as fissures, proctitis, or trauma. Stool should be tested for occult blood.

HIV is neurotropic, and neuropsychiatry complications occur at some point in the course of as many as 80% of patients with HIV disease. A carefully documented baseline neurologic examination, including cranial nerves testing and evaluations of sensation, strength, coordination, and reflexes, should be part of the initial evaluation. Results of simple tests of memory, orientation, concentration, and calculation should also be re­corded.