Obtaining the Fever history

Definition of fever

a) A documented body temperature higher than 38 degrees C or 100.4 degrees F.
b) An abnormal elevation of body temperature, usually as a result of a pathologic process.


Fever of unknown origin

a) fever of more than 3 weeks, with temperature higher than 38.3 °C on several occasions, the cause of which remains uncertain after 1 week of in-hospital diagnostic workup [Petersdorf and Beeson, 1961]

b) Modified Criteria of fever of unknown origin (Durrack & Street, 1990)
(i) The distinction between classical FUO and three other types; nosocomial, neutropenic and Human Immunodeficiency Virus (HIV)-associated FUO
(ii) The shorter duration of the investigation before a case meets the FUO criteria, i.e. three outpatient visits or 3 days (instead of 1 week) of in-hospital evaluation


History:

1)Onset (sudden vs. gradual)

2)High grade vs. low grade

3)Duration of the fever

4)Fever pattern (ask about heart rate as well)

a)Remittent fever
Daily elevated temperature of more than 38C but return to the baseline (but not normal)

b)Intermittent
Intermittently elevated temperature of more than 38C but return to baseline and normal

c)Sustained or continuous fever
Daily elevated temperature of more than 38C with fluctuation of elevated temperature (less than 0.3C)

d)Hectic fever
Daily elevated temperature of more than 38C with temperature excursion more than 1.4C. It could be either remittent or intermittent

e)Pulse temperature dissociation
Pulse slower than normal for fever degree.

f)Undulant fever
Undulant, rising and falling like a wave; bouts of continuous or remittent fever for several days, followed by afebrile remissions lasting a variable number of days

g)Quotidian fever
Happening every day or once a day.


5)When it occurs (through out the day, at night, dawn, day time)

6)Severity
In relation to patient’s daily life, worsening of symptoms, disturbs the patient (inability to sleep, excessive vomiting, bed ridden, unable to take orally)

7)sign of sepsis

8)Level of consciousness.

9)Associated symptoms

a) Viral infection (coryza, headache, loss of appetite)
b) Upper respiratory tract infection (dysphagia, sore throat, coryza)
c) Lower respiratory tract infection (cough, chest pain, shortness of breath)
d) GIT symptoms (diarrhea; watery or mucous, abdominal pain, constipation)
e) GUT (Pain on micturation, hesitancy, urgency)

Others: skin lesion (rash, infection), night sweat, musculoskeletal pain, fitting, neck stiffness, constitutional symptoms, chills & rigors (pneumonia, liver abscess, pyelonephritis


10)Important history not to be missed

a) Travel history
b) Epidemiology (known area for dengue, malaria, chikugunya, worm infestation)
c) Eating outside of house
d) Other family members affected
e) Substance abuse and other drug history
f) Sexual history if suspected sexually transmitted disease.
g) Animal contact
h) Recent immunization
i) Occupational history
j) In neonate, it is important to elicit history of PROM more than 12 hours, cross infection from the mother, admission to NICU, pre term.
k) Seasonal or weather change.


11) Off set (medication, self limiting)


Reference:

1)Ami Schattner, "Letter to editor:The patient’s history remains a powerful tool in the diagnosis of fever of unknown origin", European Journal of Internal Medicine 16 (2005) 63
2)Chantal P Bleeker-Rovers, Jos WM van der Meer & Nick J Beeching, "Fever", Medicine 37:1, 2008
3)John Murtagh, "General Practice 3rd edition"
4)John Yates & Penelope Smith, " Fever and Rash", Medicine 38:1,2009
5)Stamatis P. Efstathiou, Angelos V. Pefanis, Aphrodite G. Tsiakou et al, " Fever of unknown origin: Discrimination between infectious and non-infectious causes", European Journal of Internal Medicine 21 (2010) 137–143