The patient condition was relieved when he takes paracetamol. does exercise, cold air or pollen make it worse? septic arthritis), Dermatological: rash, erythema, skin breaks (e.g. Fever was associated with chills and rigors. Screen for current symptoms suggestive of underlying infection including: Ask the patient if they have had any recent infections and if so gather more details including: Ask the patient if they have potentially been exposed to sources of infection locally including: Take a thorough travel history to identify areas in which the patient may have been infected: Screen for clinical features of autoimmune disease including: Screen for clinical features of malignancy including: 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. What was the day and time of the last fever? Order tests, such as blood tests or a chest X-ray, as needed, based on your medical history and physical examBecause a fever can indicate a serious illness in a young infant, especially one 28 days or younger, your baby might be admitted to the hospital for testing and treatment. Medical history relevant to PUO includes: Surgical history relevant to PUO includes: Ask if the patient is currently taking any prescribed medications or over-the-counter remedies: If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. Has a fever … Dry eyes and/or mouth: associated with Sjogren’s syndrome. This is a very serious condition that can damage the liver and brain. Specific causes of fever vary depending on the patient's destination. We reviewed electrical medical record to check whether history-taking included questions on fever pattern in febrile patients. Gain consent to proceed with history taking. Occupation 6. 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). What was the day and time of the first fever? water-based activity, animal contact). These two types of signals are integrated by the thermoregulatory center of the hypothalamus to maintain normal temperature. Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience. Unlike most other fever-of-unknown-origin reviews, this article presents a clinical approach. PACES Station 2: HISTORY TAKING Patient details: Mr John Davidson, a 25-year-old man Your role: You are the doctor in the medical admissions unit Presenting complaint: Fever Please read the letter printed below. Step 05 - Drug History (DH) Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. 2012School of Clinical Medicine Clinical Skills NRMSM UKZN Dr RM Abraham. Sex 4. You have 14 minutes ), shivering (to raise temperature by muscle activity) and vasoregulation (constriction and dilatation). The central thermostat is situated in the hypothalamus. Heat and cold sensitive neurons are located in the anterior hypothalamus and pre-optic areas. Temperature information from peripheral receptors is integrated in the hypothalamus , allowing modulation of the body’s heat production, conservation and loss. This is controlled by neuronal mechanisms involving the limbic system, lower brain stem, spinal cord and autonomic nerves. Temperature in healthy adults is tightly controlled at a mean of 36.8C; there is however a physiological diurnal variation of approx 0.5C, with the maximum occurring btw 4 and 8pm and the minimum btw 2 and 6am. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. house, bungalow) and if there are any adaptations to assist them (e.g. Taking a Fever History It is important to take a fever history to distinguish dengu e from other infectious and noninfectious diseases. Start typing to see results or hit ESC to close, DNACPR Discussion and Documentation – OSCE Guide, Cervical Spine X-ray Interpretation – OSCE Guide, Musculoskeletal (MSK) X-ray Interpretation – OSCE Guide, medical MCQ quiz platform at, Introduction to Trans – Definitions and FAQs, Dermatological History Taking – OSCE Guide, Bacterial infections (e.g. For example: 'So, Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing - particularly meat - and the whole thing's been getting you down. Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”, What you plan to cover next: “Next I’d like to discuss your past medical history and then explore what medications you currently take.”. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. See our Privacy Policy and User Agreement for details. ²,³, The most common causes of PUO include the following: 4. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Vasculitis (plural: vasculitides) refers to a heterogeneous group of disorders that are characterized by inflammatory destruction of blood vessels. Smoking is a significant risk factor for malignancy and impairs immune function. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. do you get heartburn? Characteristic fever patterns of malarial infection are clues for diagnosis. It is important for physicians to be diligent, as the differential diagnosis can include […] Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. uncrossed legs and arms, leaning slightly forward in the chair). 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. contaminated water, animals). Bacterial infections (e.g. Age 3. #x203A; Fever is perhaps the most ancient hallmark of disease. General history taking ..... 57. Change in bowel habit (including blood in stool), Previous and current infections (e.g. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. twice daily carer visits). tuberculosis), Cardiovascular: chest pain (e.g. If you continue browsing the site, you agree to the use of cookies on this website. General Presentation Children frequently present at the physician’s office or emergency room with a fever and rash. Normal body temperature is 37 C or 98.6 F. variation of 1 degree F between morning and evening temperature is normal. Free medical revision on history taking skills for medical student exams, finals, OSCEs and MRCP PACES. Campylobacter jejuni), Hepatic: jaundice, nausea, right upper quadrant tenderness (e.g. Treatment typically involves resting and drinking fluids. › The oldest civilizations (Egyptian, Mesopotamian, Chinese, Indian, and Greek) demonstrated extensive knowledge of anatomy and physiology, but they tended to view fever as being induced by evil spirits. Name 2. Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next. As in any other disease history of the illness is important for a good clinical management. cellulitis, Kawasaki’s disease), the type of infection and if this was confirmed (e.g. Religion 5. 1: Hyperthermia A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Call the doctor if the fever is accompanied by a severe headache, stiff neck, shortness of breath, or other unusual signs or symptoms. 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. cerebral abscess, encephalitis), Musculoskeletal: joint pain and swelling (e.g. Although the differential diagnosis is very broad, adequate history and physical examination can help the clinician narrow down a list of more probable etiologies. 2. Neurons in both the preoptic anterior hypothalamus and the posterior hypothalamus receive two kinds of signals: one from peripheral nerves that reflect warmth/cold receptors and the other from the temperature of the blood bathing the region. Active listening: through body language and your verbal responses to what the patient has said. 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. ²,³ The most common causes of PUO include the following: 4 1. A collection of surgery revision notes covering key surgical topics. It has been historically used to describe a subacute presentation of a single illness of at least 3 weeks' duration during which a fever >38.3°C (100.9°F) is present for most days and the diagnosis is unclear after 1 week of intense investigation. Dispose of PPE appropriately and wash your hands. A birth weight of less than 2500 g, rupture of membranes before the onset of labor, septic or traumatic delivery, fetal hypoxia, maternal per… 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 collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. INTRODUCTION • FEVER(Pyrexia) Is an elevation of body temperature above the normal circadian range (daily variation) as a result of a change in the thermoregulatory center located in the anterior hypothalamus and pre-optic area (i.e. [27] The depth of involvement is what differentiates a nodule from a papulePapule-A papule is a circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to less than either 5[28] or 10 mm in diameter at the widest point, Living conditionsIf in squatter’s area-reflect on the lifestyle of Pt, easy transmissibility of other infections due overpopulation within the area, hygiene and cleanlinessIf living near a body of water-especially stagnant water, may bring about the possibility of contracting the disease from vectors for example: mosquitoes (Dengue) Source of water-may indicate if water-borne pathogens have a role in the disease (Typhoid, Cholera)Geographic area of living-Malaria-Saudi (malaria area)/Africa/IndiaBrucella-Saudi/Gulf AreaTyphoid-India/Pakistan/Egypt/IndonesiaHistoplasmosis-USA (West Coast)Tuberculosis, Liver Abscess, AIDS- All over the world, Which countries and regions were visited, arrival and departure datesDetails of living hx including living and sleeping conditions, whether bed nets were used, what type of food and water was consumed and whether there was any contact with animals, hospitals or fresh water.Sexual hx-Unprotected sexual intercourse with a commercial sex worker, 1. Intravenous drug use is associated with an increased risk of developing blood-borne infections including HIV, hepatitis B/C and bacterial infections (e.g. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next. Introduce yourself to the patient including your name and role. Record the frequency, type and volume of alcohol consumed on a weekly basis. HISTORY TAKING IN FEBRILEPATIENTS Using the Calgary Cambridge guide as a framework to interviewing patients. 11:16. This guide provides a structured approach to taking a history from a patient with pyrexia of unknown origin (PUO) in an OSCE setting. Cardiovascular history ..... 61. Respiratory: cough, dyspnoea, haemoptysis (e.g. Demonstrating empathy in response to patient cues: both verbal and non-verbal. At this point it is a good idea to find out if the patient has any allergies. Ask about the patient’s current occupation to identify any potential exposure to infectious diseases (e.g. systemic lupus erythematosus, sarcoidosis, rheumatoid arthritis), Immunosuppressants (e.g. To evaluate a fever, your doctor may: 1. PUO is defined as fever of 38.3°C or greater for at least 3 weeks with no identified cause after three days of hospital evaluation or three outpatient visits.¹Additional categories of PUO have since been added, including nosocomial, neutropenic and HIV-associated PUO. The definition of fever of unknown origin (FUO), as based on a case series of 100 patients,3 calls for a temperature higher than 38.3°C on several occasions; a fever lasting more than three weeks; and a failure to reach a diagnosis despite one week of inpatient investigation. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. abscesses, endocarditis, tuberculosis, osteomye… joint replacement): Take an immunisation history to ensure the patient has received all of the relevant vaccinations: Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. Continue to periodically summarise as you move through the rest of the history. History of present illness should note degree and duration of fever, method of measurement, and the dose and frequency of antipyretics (if any). rheumatoid arthritis, mixed connective tissue disease, polymyalgia rheumatica), Malignancy (e.g. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. It is produced by lymphocytes expressing the surface antigens CD4 and CD8. We’ve broken down the history of presenting complaint into several areas of focus including: Take a comprehensive history of the patient’s fever. 1. Dr. Louise Gooch, ward doctor) Identity: confirm you’re speaking to the correct patient (name and date of birth) Learn more about viral fever … Factitious fever this is defined as fever engineered by the patient by manipulating the thermometer andor … self-hygiene, housework, food shopping), if they have any carer input (e.g. Both arteries and veins are affected. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. After taking the history, it's useful to give the patient a run-down of what they've told you as you understand it. History taking in patients - FEVER routine questions Routine questions about cardinal symptoms: Symptom 02: Fever. A powerpoint presentation on Approach to history taking in a patient with a fever.. Looks like you’ve clipped this slide to already. endocarditis). It is also important to ask about any complications associated with the condition including hospital admissions. Some experts have argued for a more comprehensive defi… Alcohol is a significant risk factor for malignancy and impairs immune function. an increase in the Wash your hands and don PPE if appropriate. Facilitate the patient to expand on their presenting complaint if required: History taking typically involves a combination of open and closed questions. D.O.E (Date Of Examination) Explain that you’d like to take a history from the patient. An appropriate level of eye contact throughout the consultation. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Making sure not to interrupt the patient throughout the consultation. Explore the patient’s ideas about the current issue: Explore the patient’s current concerns: Ask what the patient hopes to gain from the consultation: Summarise what the patient has told you about their presenting complaint. Ask if the patient has previously undergone any surgery or procedures (e.g. It dates back as far as civilization itself. Some general communication skills which apply to all patient consultations include: Use open questioning to explore the patient’s presenting complaint: Provide the patient with enough time to answer and avoid interrupting them. Rashes: associated with lupus (butterfly rash), sarcoidosis (erythema nodosum) and adult-onset Still’s disease (salmon-pink coloured rash). Fever of short duration [ I would like to define it as less than 2 weeks] is perhaps the most challenging problem in clinical practice. Dry cough: associated with several connective tissue diseases including sarcoidosis. Body temperature is controlled by the hypothalamus. In contrast, fever of unknown origin is not well defined in children. Fever is a common symptom. An inconsistent history should raise the suspicion of a factitious fever or Munchausen syndrome by proxy. Ensure you initially keep a comfortable distance, establishing eye contact and rapportwith the family. urinary tract infection, sexually transmitted infection), Central nervous system: headache, photophobia, seizures, confusion (e.g. When taking a history from a patient with PUO you need to ask a broad range of questions to help narrow the differential diagnosis. Biomedical perspective- to understand the chronology of symptoms, analyse each symptom and review each system to localize the source of the … See our User Agreement and Privacy Policy. History taking should always have an objective which … History of present illness sample fever. There are many causes. Explore the patient’s general social context including: Record the patient’s smoking history, including the type and amount of tobacco used. Clipping is a handy way to collect important slides you want to go back to later. Some form of hpi is required for each level of care for every type of em encounter. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.2 and 38.3 °C (99.0 and 100.9 °F) in humans. Learning in 10 3,980 views. No public clipboards found for this slide, Approach to history taking in a patient with fever. pericarditis), Gastrointestinal: abdominal pain, diarrhoea (e.g. A review of the prenatal history, including maternal history of sexually transmitted infections (human immunodeficiency virus [HIV], hepatitis B and hepatitis C, syphilis, gonorrhea, chlamydia, herpes simplex), maternal group B Streptococcus(GBS) status and prophylaxis, mode of delivery, prolonged rupture of membranes, and history of maternal fever should be noted. mild rash vs anaphylaxis). Check out our brand new medical MCQ quiz platform at Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Discoloured fingers and toes: may be caused by Raynaud’s phenomenon which is associated with connective tissue diseases such as rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis.  Human metabolic processes are temperature dependent, and an individual’s body temperature rarely varies by more than 1C from baseline. The peripheral effector mechanisms are sweating (to reduce temp. Title: HISTORY TAKING OF FEVER 1 HISTORY TAKING OF FEVER 2 Anamnesis (auto anamnesis and/or hetero anamnesis) Physical Examination Laboratory Analysis Others Diagnostic modalities Differenti al Diagnosis Working Diagnosis 3 Beginning of … hepatitis), Genitourinary: dysuria, frequency, haematuria, urethral discharge (e.g. A collection of free medical student quizzes to put your medical and surgical knowledge to the test! HPC- history of presenting complaintPMH- Past medical history, URTI- Upper resp tract infectionLRTI- Lower resp tract infection, Macule – A macule is a change in surface color, without elevation or depression and, therefore, nonpalpable, well or ill-defined,[28] variously sized, but generally considered less than either 5[28] or 10 mm in diameter at the widest point.Vesicle – A vesicle is a circumscribed, fluid-containing, epidermal elevation generally considered less than either 5[28] or 10 mm in diameter at the widest pointNodule – A nodule is morphologically similar to a papule, but is greater than either 5[26] or 10 mm in both width and depth, and most frequently centered in the dermis or subcutaneous fat. healthcare worker, exposure to animals). The most important step is taking a meticulous detailed history to explore the patients problems from three perspectives. corticosteroids, methotrexate, azathioprine, tacrolimus, biologics), the type of accommodation they currently reside in (e.g. breaks in the skin), recreational drug use (intravenous and intranasal), Chemoprophylaxis and compliance (e.g. Now customize the name of a clipboard to store your clips. A recent study suggests that with modern thermometers, an early morning temperature of greater than 99.0°F or an evening temperature of 100.0°F should be considered abnormal. D.O.A (Date Of Admission) 8. If the fever is due to chickenpox, influenza or certain other viral infections, taking aspirin can increase the risk of Reye’s syndrome. Ask if there are any triggers or exacerbating factors for the fever: Ask if anything seems to improve the fevers: Ask if there are other symptoms which are associated with the fever: Ask the patient if they have been recording their fevers and if so what those readings were: Explore the patient’s history for evidence of underlying infectious disease. Ask the patient if they have any questions or concerns that have not been addressed. This strict definition prevents common and self-limiting medical conditions from being included as FUO. diabetes, myeloma, transplant recipient), Autoimmune disease (e.g. Address 7. Case presentation of fever • The story started as high grade intermittent fever that started abruptly on the several few days. Fever: A rise in body temperature in response to endogenous cytokines. If you continue browsing the site, you agree to the use of cookies on this website. Ask the patient if they’re currently experiencing any side effects from their medication: Relevant medications in the context of PUO include: Ask the patient if there is any family history of cancer or autoimmune conditions: Ask if any of the patient’s close family members currently have any serious infections such as tuberculosis: Explore the patient’s social history to understand their social context. You can change your ad preferences anytime. asking the patient how they are and offering them a seat). Ask about the patient’s current hobbies to identify potential exposure to infectious diseases (e.g. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Viral fever symptoms include a high temperature, coughing, nausea, and a runny nose. malarone for malaria), Activities (e.g. Ask questions about your symptoms and medical history 2. Febrile Phase • Does the patient still … This will help ensure your consultation is more natural, patient-centred and not overly formulaic. Pyrexia of unknown origin (PUO) is defined as fever of 38.3°C or greater for at least 3 weeks with no identified cause after three days of hospital evaluation or three outpatient visits.¹ Additional categories of PUO have since been added, including nosocomial, neutropenic and HIV-associated PUO.