Nursing assessment of the patient with primary HIV infection: key to improving clinical recognition. (Clinical Considerations).

David is a 29-year-old Hispanic male who presents complaining of fatigue, headache, muscle aches, a sore throat, and nausea. Physical assessment demonstrates an erythematous maculopapular rash on the trunk and symmetric adenopathy. His temperature is 37.6 [degrees] C; other vital signs are within normal limits. Laboratory findings include a white blood cell count of 4.5/[micro]L and a platelet count of 98,000/[mm.sup.3]. Blood chemistry is unremarkable. David states that his symptoms began one week ago.

**********

Subsequent laboratory testing will confirm that David has acute retroviral syndrome, which accompanies primary HIV infection (PHI), also known as acute HIV infection. But the odds are high that in almost every emergency room or physician's office in the country, David will be misdiagnosed. He is likely to be told that he has a "viral syndrome," probably the flu, and sent home with instructions for supportive care.

Except for advanced practitioners, registered nurses do not diagnose. But a proper nursing assessment, which includes physical examination, history taking, and review of laboratory studies, can go a long way in aiding an accurate medical diagnosis. In many health care settings, patients encounter a registered nurse well before seeing a physician or nurse practitioner. Assessment and history taking begin with the nurse.

According to the Centers for Disease Control and Prevention, approximately 40,000 US residents become HIV infected annually. Although some will pass asymptomatically through primary infection, between 50% and 90% will be symptomatic. Of these, the exact number who present for medical care is unknown. But of those who do seek care, the vast majority will receive an erroneous diagnosis, according to the Annals of Internal Medicine (134, p.75, 2001). Given the large role registered nurses play in the nation's health care system, especially their significance in the emergency room, the failure to identify most PHI cases may not change until RNs are trained to suspect it.

David's presenting complaint is illuminated by history taking. The nurse can tailor appropriate questioning to determine the level and nature of his risk for HIV infection. Has he had a high-risk sexual exposure to HIV in the last 6 weeks? Does he have a history of intravenous drug use? If he reports behavior consistent with HIV transmission, when was the last episode of that behavior in relation to the start of his symptoms?

Does the physical exam further heighten suspicion of primary HIV infection? In David's case, for example, he has a rash. Rash does not generally accompany the flu. Does he have ulcerations in the mouth or genitals? Neither a rash nor genital ulceration proves acute HIV infection. But both signs are consistent with it, and in the context of a history of high-risk exposure, they indicate that HIV-specific laboratory studies may be warranted. In charting the nursing assessment, these findings should be drawn to the attention to the attending clinician.

Standard laboratory studies are also useful in isolating HIV as the culprit of a flu-like illness. The nurse may note leukopenia and thrombocytopenia on a complete blood count report. Again, while these results do not prove HIV, they are suggestive.

Based on examination, history, and laboratory study, the nurse can, without offering a medical diagnosis, note on the chart: "History, signs, and symptoms consistent with primary HIV infection." This is the stating of facts without the drawing of a medical conclusion. The idea is not to diagnosis the case, which the registered nurse is not lawfully allowed to do, but to draw to the attention of the attending clinician the possibility of acute HIV infection.

The accurate diagnosis of patients presenting for health care is the ultimate responsibility of the medical profession. However, it is undeniably true that if registered nurses learn to identify and flag possible cases of PHI, the rate of accurate diagnosis in these cases would rise dramatically.

Flagging might mean drawing informal, verbal notice to the case, as in, "Doctor, with this next case, you may wish to consider primary HIV infection in your differential." In settings where the registered nurse has earned the confidence of the physician and professional relations are cordial, a respectful verbal suggestion is almost invariably enough to elicit the desired follow-up. On the other hand, in large, impersonal teaching institutions, more concrete notation may be needed. A statement in the chart noting that the patient's history, signs, and symptoms are consistent with primary HIV infection is factual and attention-getting without making a diagnosis. It is the rare resident who ignores the evidence-based notations of an experienced nurse.

For the reasons outlined elsewhere in this issue, the diagnosis of primary HIV infection is a medical emergency. Once the acute retroviral syndrome has resolved, the potential benefits of an accurate PHI diagnosis resolve with it. The opportunities for the patient to enter a study of acute infection, for the clinician to offer education on the highly infectious nature of PHI, for the possible preservation of HIV-specific immunity, and for testing for the presence of drug-resistant virus are all lost.

With the annual number of new infections now holding steady at 40,000, America faces a permanent epidemic of HIV. The numbers are unlikely to go down--and the potential benefits of care and research, impossible to exploit--until patients with PHI can walk into a health care setting and get an accurate diagnosis. That may not happen until America's nurses, long at the vanguard of public health, take the lead in recognizing the signs and symptoms of primary HIV infection.