Previously, we discussed how to take patient history clinically. In this blog, we will discover which questions to ask the patient regarding his fever and approach the possible differential diagnosis by revealing more about fever. Perhaps fever history taking format should be a chapter in itself, but it is always better to memorize these questions as they are FAQs of medical life. Always try to make patient comfortable and don’t hassle or mix up, otherwise it may become cumbersome for both you and patient. The history taking for fever in patients goes as follow:

Defining Fever

You don’t even know the definition of Pyrexia and you are up for history taking for fever. You are either doomed or you are not serious really. Have a look below.

Q1- Did you suffer any fever recently?

Answer- Yes/No

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It is the basic question to approaching chief complaints of patient. Normal body temperature ranges between 98-99 F. However, pyrexia or fever is defined as temperature above 99 F, Hypothermia below 95 F and Hyperpyrexia above 106.7 F. Thermometer is placed for 2 minutes either below tongue in mouth (oral), below armpits (Axillary) or in rectum (Rectal). Preciseness order goes as Rectal>Oral>Axillary.

Fever History Proper

Let’s dive into the basics of Fever history and explain bit on the format. The following questions will cover up, just have a look at the basics:

Q2- Was the fever continuous or just for few hours?

Answer- Continuous/Few hours

Fever is of 3 types:

  1. Intermittent- for several hours, then touches baseline (i.e, normal temp) sometime during day.
    Causes- See Intermittent fever types in Question 3
  2. Continuous- No fluctuations greater than 1.5 F and never touches baseline.
    Causes- Lobar pneumonia, Rheumatic fever, Miliary Tb, 2nd week of enteric fever, Meningococcal meningitis
  3. Remittent- Fluctuations greater than 3 F and never touches baseline (alternate of continuous).
    Causes- Amoebic liver abscess, Urinary tract infection (UTI), 3rd week of Enteric fever, Acute bronchopneumonia, Acute tonsillitis, Bacteraemia, Septicemia, Pyaemia.

Q3- Does the fever occur daily or alternate days?

Answer- Daily/Alternate days

Again, it goes as Intermittent type of fever. 3 types of intermittent fever are:

  1. Quotidian- Daily
    Causes- Double infection of P. vivax, Pent-up pus anywhere in body, Tuberculosis, UTI, Septicaemia
  2. Tertian- Alternate days
    Causes- Benign tertian malaria, Malignant tertian malaria
  3. Quartan- 2 days interval
    Causes- P. malaria-quartan malaria (rare in india)

Q4- Is the fever stable (No fluctuations above 1.5 F) or unstable (Fluctuations above 3 F) and sustained?

Answer- Stable/Unstable

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Again, it helps in finding if patient has Continuous fever type or Remittent fever type.

Q5- Does the fever falls to normal within 6-12 hours with sweating or it falls to normal gradually over days?

Answer- 6-12 hours/Days

  1. If fever falls to normal within 6-12 hours, it is called Fall by Crisis.
    Causes- Acute lobar pneumonia, Enteric fever with intestinal hemorrhage, Adrenal crisis, Septicemic shock, Dengue, Anti-pyretic drugs
  2. If fever falls gradually over days, it is called Fall by Lysis.
    Causes- Uncomplicated enteric fever, Rheumatic fever, Acute bronchopneumonia

Fever Associations

Since we have covered the basics of Fever history, its time we move to the detailed part of the format and discover what can be related to our patient having the fever of unknown origin:

Q6- Is the fever associated with Chills and Rigors?

Answer- Yes/No

Chills is feeling intense cold, while shivering is Rigor.

Causes- Malaria, UTI, Pent-up pus anywhere in body, Septicemia/Pyaemia, Cholangitis, Sub-acute Bacterial Endocarditis, Thrombophlebitis, Acute pyelitis/Pyelonephritis, Acute lobar pneumonia, Agranulocytosis, Pyogen reaction (fluid/blood transfusion), Filariasis, Jaundice.

Q7- Is the fever associated with sweating?

Answer- Yes/No

Sweating is associated with Hectic Temperature which is Chills and Rigors followed by profuse sweating and then normal temperature.

Causes- Pent-up pus anywhere in body (lung/liver/sub-diaphragmatic abscess, empyema thoracis, empyema of gall bladder), Septicemia/Pyaemia, Advanced TB (rarely)

Q8- Is the fever associated with cold sores on lips?

Answer- Yes/No

Cold sores are painful, tender vesicles on outer surface of lips/Fever blisters on lips.

Causes- Acute lobar pneumonia, Influenza, Malaria, Meningococcal meningitis, Weil’s disease, Mycoplasma pneumonia infection, AIDS, Physiological- sunlight or menstruation.

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Q9- Is there appearance of Rash anywhere during the fever?

Answer- Yes/No

Causes- Mnemonic- Very Sick Person Must Take Double Tea

  • 1st day- Varicella, i.e, Chickenpox
  • 2nd day- Scarlet fever
  • 3rd day- Pox (Smallpox, not seen these days)
  • 4th day- Measles
  • 5th day- Typhus
  • 6th day- Dengue
  • 7th day- Typhoid/Enteric fever

Q10- Is there history of any recent convulsions?

Answer- Yes/No

Pyrexia or fever is generally normal after convulsions (GTCS) due to excessive body muscle contraction. These are short lived (less than 5 mins).

Answer- Yes if any/No

Certain drugs can cause fever, i.e, Pyrexia inducing drugs which are:

Sulfonamides, Phenytoin, Iodides, Bromides, Thiouracils, Barbiturates, Penicillin, Salicylates, Rifampcin, Phenopthalein (used in laxatives), Quinidine.

NOTE: Normal fever generally has Eosinopenia while drug induced fever shows eosinophilia in Differential Leucocyte Count (DLC) of blood.

Q11- What is the drug/medicine history?

Answer- Yes if any/No

Certain drugs can cause fever, i.e, Pyrexia inducing drugs which are :-

Sulfonamides, Phenytoin, Iodides, Bromides, Thiouracils, Barbiturates, Penicillin, Salicylates, Rifampcin, Phenopthalein (used in laxatives), Quinidine.

NOTE: Normal fever generally has Eosinopenia while drug induced fever shows eosinophilia in Differential Leucocyte Count (DLC) of blood.

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