Pyrexia of Unknown Origin (PUO) – History

Free medical revision on history taking skills for medical student exams, finals, OSCEs and MRCP PACES

Introduction (WIIPP)

  • Wash your hands
  • Introduce yourself: give your name and your job
  • Identity: confirm you’re speaking to the correct patient (name and date of birth)
  • Permission: confirm the reason for seeing the patient (“I’m going to ask you some questions about how you’re feeling, is that OK?”)
  • Positioning: patient sitting in chair approximately a metre away from you. Ensure you are sitting at the same level as them and ideally not behind a desk

 

History of presenting complaint

  • Onset: when was temperature first noted; sudden or gradual onset
  • Character: constant or intermittent
    • Frequent peaks in temperature?
    • Has the temperature actually being recorded, if so how high?
  • Alleviating factors: rest, paracetamol, ibuprofen
  • Timing: night or day, related to exertion?
  • Associated symptoms/signs (systematic)
    • Shivering or rigors (rigors are violent uncontrollable shivering)
    • Sweating (night sweats are particularly important: these are drenching and often require a change of bedclothes)
    • Weight loss
      • Quantify how much weight has been lost and over how long
    • Anorexia (loss of appetite)
    • Feeling faint or dizzy; syncope
    • Fatigue (has it interfered with daily life?)
  • Associated symptoms/signs (systems-based)
    • Sore throat; difficulty swallowing; ear pain (ENT infection)
    • Cough and sputum (lower respiratory tract infection)
    • Diarrhoea and vomiting; abdominal pain (gastroenteritis)
    • Urinary frequency; dysuria; haematuria (urinary tract infection)
    • Rashes or skin changes; areas of erythema (viral illness or cellulitis)
    • Headache, neck stiffness, photophobia (meningitis)
      • Note this picture with a rash implies meningococcal septicaemia
    • New heart murmur; symptoms of heart failure; lethargy; splinter haemorrhages; Janeway lesions; Osler’s nodes; Roth spots; microscopic haematuria (infective endocarditis)
    • Lumps or bumps (any tender lymph nodes?)
      • Non-specific but can suggest haematological malignancy

 

Past medical history

  • Full past medical history but particularly:
  • Previous fevers
  • Immunosuppression
    • On steroids, chemotherapy or other immunosuppressive medication
  •  Tuberculosis
    • When? Where? Was it drug resistant?
    • What previous treatment given and for how long? (If not sure re: dosing, did their urine go orange? – implies given rifampicin)
  • HIV
    • When diagnosed?When started treatment? Previous treatment? Current treatment?
    • Adherence to medications?
    • Who are they usually looked after by? Do they know their last CD4 count and viral load?
  • Recent surgery (possible abscess)
    • Including dental procedures
  • Recent illnesses (including viral) and antibiotic courses
    • Possibility of super-added bacterial infection or not fully treated previous infection

 

Drug history

  • Full drug history including over-the-counter (OTC) and recreational drugs
  • Intravenous drug use (IVDU)?
    • Ever?!
    • If so did they needle share? Are very aware of their last hepatitis and HIV serology?
  • Immunisations up-to-date?

 

Family history

  • Any family members with contagious diseases (tuberculosis or viral illness)

 

Social history

  • General
    • Smoking; alcohol (alcoholism is a TB/HIV risk factor)
  • Occupation
    • Any contact with animals or the outdoors (zoonotic infections)
  • TB risks
    • Contact with people with TB
    • Recent visit to, or relative visiting from, TB endemic areas
    • Homeless; poor nutrition
  • HIV and hepatitis risks
    • Sexual contact (see below)
    • IVDU
    • Blood transfusion pre-1980 or in poorly developed countries
    • Tattoos
    • Piercings

 

Sexual history

  • Recent sexual practice
  • Sexual contact with at-risk individual
    • e.g. known HIV positive partner, male-male sexual contact, sex with those from sub-Saharan Africa, sex in exchange for money, no use of barrier protection

 

Travel history

  • All travel in last year
    • Location (including villages or towns); appropriate vaccinations?
    • Diet (including eating at roadside restaurants or local food; food hygiene)
    • Swimming (especially in lakes and rivers)
    • Animal contact

 

Click here for the differential diagnosis of pyrexia of unknown origin

Perfect revision for medical student exams, finals, OSCEs and MRCP PACES

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