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

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

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

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?

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

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

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

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