Past Medical History
Past medical history is carefully reviewed for a previous diagnosis of herpetic infections; aseptic meningitis; recurrent sinusitis; skin problems such as folliculitis, staphylococcal infections, psoriasis, molluscum contagiosum, warts, persistent tinea, or seborrhea; recurrent bacterial pneumonia due to encapsulated organisms (Haemophilus influenzae, pneumococci); oral and vaginal candidiasis; abnormal Papanicolaou smear results; sexually transmitted diseases (if there is a history of syphilis, the details of treatment and serologic titers should be carefully documented); hepatitis B infection or vaccination; hepatitis C infection; TB (including history of skin testing, exposures, chest radiographs, vaccination, prophylaxis, and treatment); and gastrointestinal infections with parasitic organisms or bacterial pathogens. A travel history may be useful in assessing the risk of exposure to histoplasmosis and coccidioidomycosis.
Review of Systems
Because HIV infection is usually a multisystem disease, the review of systems takes on particular importance. It begins with inquiry into systemic symptoms (fever, chills, drenching night sweats, fatigue, weight loss), which may be manifestations of acute infection or more advanced disease. Skin complaints should be reviewed, particularly reports of violaceous nodules or plaques, pustules, petechiae, groin rashes, or herpetic lesions. Moving to the head, eyes, ears, nose, and throat review, it is important to ask about sinus pain and any purulent drainage, sore throat, coated tongue, and white patches in the pharynx. Inquiry into lymphadenopathy may prove informative.
The pulmonary review includes a check for dyspnea, persistent dry or productive cough, and hemoptysis. A nonproductive cough of recent onset in conjunction with dyspnea on exertion should raise suspicion for Pneumocystis pneumonia. Patients should be asked about gastrointestinal symptoms, especially odynophagia (painful swallowing suggestive of fungal esophagitis), abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, tenesmus, and perianal pain. Diarrhea and tenesmus suggest large-bowel pathology. Cramping periumbilical pain, diarrhea, and increased flatus point to a small-bowel process. Early satiety, anorexia, and weight loss may be manifestations of gastrointestinal lymphoma. Genitourinary involvement is screened by inquiry into abnormal vaginal bleeding or discharge, dyspareunia, urinary frequency, dysuria, and hematuria.
The neurologic review is critical. Unilateral headache becoming more generalized in conjunction with a stiff neck suggests the spread of a parameningeal focus of infection into the CNS. New onset of lateralized weakness or numbness, especially if accompanied by a worsening unilateral headache, raises the question of a mass lesion (lymphoma, toxoplasmosis, brain abscess). Monocular visual field disturbances and floaters are characteristic complaints in patients with CMV retinitis. Diplopia and homonymous hemianopsia may indicate a CNS infection or malignancy. Numbness or tingling in the fingers or toes points to a peripheral neuropathy or myelopathy.
Neuropsychiatric difficulties raise the question of HIV-associated dementia. Suggestive symptoms include cognitive problems, difficulty with concentration, memory loss, insomnia, apathy, social isolation, and alterations in mood, especially depression. When accompanied by fever and delirium, they are more likely to be the consequence of an encephalopathy, but such difficulties may also occur as a consequence of a reactive depression. Distinguishing among these conditions can sometimes be difficult and may require neuropsychiatric testing and other diagnostic tests.