Skip to content

11/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history

Pyrexia of unknown origin (PUO) history

Table of contents

Background

PUO is de
or three outpatient visits.
¹Additional categories of PUO have since been added, including nosocomial, neutropenic and HIV-
associated PUO.
2,3
The most common causes of PUO include the following\:
4
Bacterial infections (e.g. abscesses, endocarditis, tuberculosis, osteomyelitis)
Viral infections (e.g. CMV, EBV, HIV)
Autoimmune conditions (e.g. rheumatoid arthritis, mixed connective tissue disease, polymyalgia rheumatica)
Malignancy (e.g. Hodgkin's/non-Hodgkin's lymphoma)

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 1/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

When taking a history from a patient with PUO you need to ask a broad range of questions to help narrow the di
diagnosis. We've broken down the history of presenting complaint into several areas of focus including\:
Fever
Infectious disease
Autoimmune disease
Malignancy

Fever

Take a comprehensive history of the patient's fever.
Onset and duration
Clarify when the fever developed\:
" W h e n d i d y o u
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g f e v e r s ?"
Time course
Ask how the fever has changed over time\:
" H o w f r e q u e n t l y h a v e y o u b e e n e x p e r i e n c i n g t h e f e v e r ?"
" H a s t h e f r e q u e n c y o f t h e f e v e r c h a n ge d s i n c e i t
" I s t h e r e a n y c l e a r p a t t e r n t o t h e f e v e r ?"
Triggers
Ask if there are any triggers or exacerbating factors for the fever\:
" W a s t h e r e a n y o b v i o u s t r i g g e r t h a t p r e c e d e d t h e o n s e t o f f e v e r s ?"
Relieving factors
Ask if anything seems to improve the fevers\:
" D o e s a n y t h i n g r e d u c e t h e f r e q u e n c y o r s e v e r i t y o f t h e f e v e r s ?"
Associated features
Ask if there are other symptoms which are associated with the fever\:
Malaise
Nausea/vomiting
Night sweats
Fatigue
Rigors
Weight loss
https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 2/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
Pain (clarify location)
Swelling (abscess, lymphadenopathy)
Skin changes (e.g. rash, itch)
Severity
Ask the patient if they have been recording their fevers and if so what those readings were\:
" D i d y o u m e a s u r e y o u r t e m p e r a t u r e a t h o m e ?"
" D o y o u r e m e m b e r w h a t y o u r h i g h e s t t e m p e r a t u r e w a s ?"

Infectious disease

Explore the patient's history for evidence of underlying infectious disease.
Current infectious symptoms
Screen for current symptoms suggestive of underlying infection including\:
Respiratory\: cough, dyspnoea, haemoptysis (e.g. tuberculosis)
Cardiovascular\: chest pain (e.g. pericarditis)
Gastrointestinal\: abdominal pain, diarrhoea (e.g. Campylobacter jejuni)
Hepatic\: jaundice, nausea, right upper quadrant tenderness (e.g. hepatitis)
Genitourinary\: dysuria, frequency, haematuria, urethral discharge (e.g. urinary tract infection, sexually transmitted infection)
Central nervous system\: headache, photophobia, seizures, confusion (e.g. cerebral abscess, encephalitis)
Musculoskeletal\: joint pain and swelling (e.g. septic arthritis)
Dermatological\: rash, erythema, skin breaks (e.g. cellulitis, Kawasaki's disease)
Recent infections
Ask the patient if they have had any recent infections and if so gather more details including\:
the type of infection and if this was con
the symptoms the patient experienced and if these have fully resolved
the treatments the patient received and if these were taken as prescribed (e.g. completing a course of antibiotics)
Local exposure
Ask the patient if they have potentially been exposed to sources of infection locally including\:
close contact with others who were unwell at the time
contaminated water or food
recent injuries (e.g. breaks in the skin)
contact with animals
sexual activity without contraception
recreational drug use (intravenous and intranasal)
Travel history
Take a thorough travel history to identify areas in which the patient may have been infected\:
Location (e.g. rural, urban)
Departure and return dates
Chemoprophylaxis and compliance (e.g. malarone for malaria)
Vaccinations
Activities (e.g. water-based activity, animal contact)
Accommodation (e.g. malaria bed nets)
Insect bites
Injuries (e.g. breaks in the skin)
Food and water consumption
Sick contacts
Sexual activity
Tattoos and piercings

Autoimmune disease

https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 3/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
Screen for clinical features of autoimmune disease including\:
Morning joint sti
Rashes\: associated with lupus (butter
coloured rash).
Discoloured
diseases such as rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis.
Headache, jaw claudication, scalp tenderness, visual loss\: suggestive of giant cell arteritis which is associated with
polymyalgia rheumatica.
Fatigue
Dry eyes and/or mouth\: associated with Sjogren's syndrome.
Red and/or painful eyes
Dry cough\: associated with several connective tissue diseases including sarcoidosis.

Malignancy

Screen for clinical features of malignancy including\:
Weight loss
Fatigue
Change in bowel habit (including blood in stool)
Haemoptysis/haematuria
Shortness of breath
Masses
Bone pain
Night sweats
Lymphadenopathy

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Summarising

https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 4/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
c u r r e n t l y t a k e .
”
“ N e x t I’ d l i k e t o d i s c u s s y o u r p a s t m e d i c a l h i s t o r y a n d t h e n e x p l o r e w h a t m e d i c a t i o n s y o u

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: weight loss (e.g. malignancy)
Cardiology\: palpitations (e.g. endocarditis)
Respiratory\: shortness of breath and cough (e.g. tuberculosis, sarcoidosis)
Gastrointestinal\: abdominal pain and diarrhoea (e.g. infective diarrhoea)
Neurological\: confusion (e.g. cerebral abscess)
Musculoskeletal\: back pain (e.g. discitis)
Dermatological\: rash, erythema, skin breaks (e.g. cellulitis, Kawasaki's disease)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. joint replacement)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Take an immunisation history to ensure the patient has received all of the relevant vaccinations\:
" C a n I j u s t c h e c k w h i c h v a c c i n a t i o n s y o u' v e h a d ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 5/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
Examples of relevant medical and surgical history
Medical history relevant to PUO includes\:
Previous and current infections (e.g. HIV, tuberculosis, endocarditis, abscesses, osteomyelitis)
Conditions associated with reduced immunity (e.g. diabetes, myeloma, transplant recipient)
Autoimmune disease (e.g. systemic lupus erythematosus, sarcoidosis, rheumatoid arthritis)
Malignancy
Surgical history relevant to PUO includes\:
Recent surgery
Previous splenectomy
Prosthetic joint replacements
Prosthetic heart valves
Metallic implants (e.g. spinal rods)
Intravenous lines (e.g. central line)
Drains

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Relevant medications
Relevant medications in the context of PUO include\:
Antibiotics
Immunosuppressants (e.g. corticosteroids, methotrexate, azathioprine, tacrolimus, biologics)
Chemotherapy

Family history

Ask the patient if there is any family history of cancer or autoimmune conditions\:
" I s t h e r e a n y h i s t o r y o f c a n c e r i n y o u r c l o s e r e l a t i v e s ?"
" I s t h e r e a n y h i s t o r y o f d i s e a s e s r e l a t e d t o t h e i m m u n e s y s t e m i n y o u r c l o s e r e l a t i v e s ?"
Ask if any of the patient's close family members currently have any serious infections such as tuberculosis\:
" D o a n y o f y o u r f a m i l y m e m b e r s c u r r e n t l y h a v e a n i n f e c t i o u s d i s e a s e a t t h e m o m e n t ?"

Social history

Explore the patient's social history to understand their social context.
General social context
https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 6/711/13/24, 8\:12 PM Guide | Pyrexia of unknown origin (PUO) history
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
if there are animals in the home
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Smoking is a signi
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol is a signi
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is associated with an increased risk of developing blood-borne infections including HIV, hepatitis B/C
and bacterial infections (e.g. endocarditis).
Occupation
Ask about the patient's current occupation to identify any potential exposure to infectious diseases (e.g. healthcare worker,
exposure to animals).
Hobbies
Ask about the patient's current hobbies to identify potential exposure to infectious diseases (e.g. contaminated water, animals).

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. Petersdorf RG, Beeson PB; F e v e r o f u n e x p l a i n e d o r i g i n \: r e p o r t o n 1 0 0 c a s e s . Medicine (Baltimore). 1961 Feb40\:1-30. Available
from\: [LINK].
2. Hayakawa K, Ramasamy B, Chandrasekar PH; F e v e r o f u n k n o w n o r i g i n \: a n e v i d e n c e-b a s e d r e v i e w . Am J Med Sci. 2012
Oct344(4)\:307-16. Available from\: [LINK].
3. Roth AR, Basello GM; A p p r o a c h t o t h e a d u l t p a t i e n t w i t h f e v e r o f u n k n o w n o r i g i n . Am Fam Physician. 2003 Dec 168(11)\:2223-8.
Available from\: [LINK].
4. Dr Laurence Knott. P y r e x i a o f U n k n o w n O r i g i n . Patient.info. Published 19th Oct 2016. Available from\: [LINK].
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/history/pyrexia-of-unknown-origin-puo-history/ 7/7