Print Friendly, PDF & Email

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

Click here for how to take history in shortness of breath