42 Pyrexia of Unknown Origin

42 Pyrexia of unknown origin

Checklist / P / MP / F
Appropriate introduction
Confirms the patient’s name and age
Explains reason for consultation
Obtains consent
Open question to elicit presenting complaint
Allows patient to open up, listens carefully, remains silent and does not interrupt the patient
Signposts: e.g. ‘Mr Smith, thank you for telling me about this problem. I would like to ask a few more detailed questions. Is that all right?’
History of presenting complaint:
•How do the patient know they had pyrexia?
•What was the temperature (if measured)?
•Onset (how it started)
•Pattern:
•Day/night/intermittent/continuous/progressive
•Peaks and troughs
•Frequency
•Exacerbating factors
•Alleviating factors (paracetamol)
•Rigors/shivers
•Lethargy
•Night sweats
•Weight loss
•Reduced urine output (septic shock)
Associated symptoms that may indicate a focus:
•Respiratory:
•Cough, sputum (pneumonia)
•Haemoptysis (cancer, tuberculosis)
•Shortness of breath
•Gastrointestinal:
•Diarrhoea (gastroenteritis)
•Bloody stools (inflammatory bowel disease)
•What/when did the patient last eat?
•Liver/gallbladder:
•Right upper quadrant pain
•Jaundice
•Neurological:
•Headache (abscess, meningism)
•Neck stiffness, rash (meningism)
•Focal neurological symptoms (abscess, encephalitis)
•Cardiovascular: chest pain, shortness of breath, haematuria (infective endocarditis)
•Urological:
•Haematuria
•Dysuria (urinary tract infection)
•Loin pain (pyelonephritis)
•Rheumatological, musculoskeletal:
•Severely painful single joint (septic arthritis)
•Pain in small joints (rheumatoid arthritis, systemic lupus erythematosus)
•Muscle pain (myositis)
•ENT: throat pain (upper respiratory tract infection, tonsillitis)
•Dental: tooth pain (tooth abscess)
•Skin: rash, inflammation, redness (cellulitis)
•Calf pain/swelling (deep vein thrombosis)
•Lumps (lymphadenopathy)
•Gynaecological symptoms:
•Vaginal bleeding/discharge (pelvic inflammatory disease)
•Use of tampons
•Risk factors for HIV:
•Multiple/new sexual partners, contact with sex workers (must signpost)
•Contraception
•Intravenous drug abuse
•Recent recurrent boils/other infections
•Asks if the patient is suffering from any other symptoms
•Asks about recent illnesses
•Previous episodes of pyrexia of unknown origin (PUO)
Past medical history:
•HIV
•Tuberculosis
•Cancer
•Valvular heart disease/replacement (infective endocarditis)
•Organ transplants
•Rheumatic fever
•Blood transfusions
•Diabetes
•Immunisations
•Recent hospital admissions
•Recent surgery: any healing wounds?
Family history:
•Tuberculosis
•Cancer
•Immunosuppressive illnesses
•Familal Mediterranean fever
Drug history:
•Immunosuppressants: cytotoxic agents, chemotherapy, steroids
•Malaria prophylaxis
•Over-the-counter medications
•Herbal remedies
Allergies
Social history:
•Recent travel history:
•Where/when/what country?
•Accommodation
•Food, water, restaurants
•Did others on holiday have same symptoms?
•Swimming in rivers, at coasts or in possible contaminated waters
•Fever on holiday
•Insect/tick bites
•Recent diet:
•Unpasteurised dairy products
•Barbecues
•Drinking water abroad
•Recent contact with farm animals
•Foreign contacts
•Alcohol, smoking, illicit drug use
•Sexual history (if appropriate and only after signposting clearly)
•Occupation
•Accommodation: any recent changes
Review of systems
Use of non-verbal cues, e.g. good eye contact, nodding head and good body posture
Systematic approach
Explores and responds to ICE:
•Ideas
•Concerns
•Expectations
Shows empathy
Non-verbal skills
Avoids technical jargon
Devises holistic management plan and addresses psychosocial issues as well as medical problems
Summarises
Offers to answer any questions
Thanks patient

OSCEs for Medical Finals, First Edition. Hamed Khan, Iqbal Khan, Akhil Gupta, Nazmul Hussain, and Sathiji Nageshwaran.