History Taking in a Patient Presenting with Fever

1. Presenting Complaint - Characterize the Fever Itself

• Onset: Sudden (suggests bacterial/viral infection, malaria) vs. gradual (TB, endocarditis, malignancy)
• Duration: Acute (<2 weeks), subacute, or prolonged (>3 weeks raises FUO criteria)
• Pattern:
  • Continuous - stays elevated throughout (typhoid, lobar pneumonia)
  • Remittent - fluctuates but never touches normal (most bacterial infections)
  • Intermittent / Quotidian - returns to normal between spikes (malaria: tertian in P. vivax, quartan in P. malariae; pyogenic abscess)
  • Hectic/Septic - wide swings, very high spikes (deep-seated abscesses)
  • Pel-Ebstein - alternating fever and afebrile periods (Hodgkin lymphoma)
• Height: Low-grade (<38.5°C) vs. high-grade (>39°C); hyperpyrexia (>41.5°C suggests CNS infection or drug reaction)
• Response to antipyretics: Complete vs. partial defervescence
• Temperature-pulse dissociation (relative bradycardia despite high fever): typhoid fever, brucellosis, leptospirosis, drug fever, factitious fever

2. Associated Symptoms - The "F.E.V.E.R" Drill

Constitutional

• Chills and rigors (violent shaking = bacteremia/malaria; mild chills = viral)
• Night sweats (TB, lymphoma, endocarditis, brucellosis)
• Weight loss (TB, malignancy, HIV, chronic infection)
• Fatigue, anorexia, malaise

Head/CNS

• Headache (meningitis, encephalitis, typhoid, malaria)
• Neck stiffness, photophobia, altered consciousness
• Seizures

Respiratory

• Cough - character, duration, productive/dry
• Sputum (color, hemoptysis)
• Shortness of breath, pleuritic chest pain
• Sore throat, ear pain, nasal discharge (upper respiratory tract)

Gastrointestinal

• Nausea, vomiting, diarrhea (enteritis, typhoid, parasites)
• Abdominal pain, jaundice (hepatitis, biliary infection, liver abscess)
• Dysentery (bloody diarrhea - amoeba, Shigella)

Urinary

• Dysuria, frequency, urgency, loin pain (UTI, pyelonephritis)
• Urethral discharge

Musculoskeletal

• Arthralgia, myalgia (viral infections, dengue, leptospirosis, brucellosis, rheumatic fever)
• Bone pain, back pain (osteomyelitis, endocarditis with emboli, Pott's spine)

Skin

• Rash - type, site of onset, direction and rate of spread
  • Centrally distributed maculopapular (viral exanthem, typhoid rose spots, drug rash)
  • Peripheral/acral (Rocky Mountain spotted fever, meningococcemia)
  • Petechiae/purpura (meningococcemia, dengue, SBE)
  • Vesicles (varicella, herpes zoster)
  • Eschar/tâche noire (rickettsial scrub typhus)
• Lymph node enlargement, swelling

Cardiac

• Palpitations, murmur history (consider endocarditis)

3. Epidemiological and Exposure History - The "DEATH" Framework

4. Past Medical History

• Prior similar febrile episodes and their diagnoses
• Known chronic diseases: diabetes, liver disease, renal failure, heart valve disease, HIV/immunosuppression
• Recent surgeries, procedures, dental work (post-procedural bacteremia, endocarditis)
• History of malignancy or recurrent infections (immunodeficiency)
• History of rheumatic fever, autoimmune disease
• Recent hospitalization (nosocomial/healthcare-associated infections)

5. Drug and Vaccination History

• All medications in the previous month: antibiotics already taken (alter culture sensitivity), chemotherapy, immunosuppressants (steroids, anti-TNF, anti-IL agents - these blunt the febrile response and mask infection), NSAIDs
• Drug fever: typically occurs 7-10 days after starting a new drug; relative bradycardia may be present
• Vaccinations received (recent vaccine reactions vs. unprotected against vaccine-preventable disease)
• Blood transfusion history (malaria, CMV, HIV, hepatitis)
• Indwelling foreign material (prosthetic valves, joint replacements, catheters, pacemakers)

6. Family History

• TB contacts in family
• Familial periodic fever syndromes (FMF, TRAPS, HIDS - especially in relevant ethnic groups)
• Malignancies

7. Social History

• Country of origin (immigrant from TB-endemic country)
• Living conditions (overcrowding, poor sanitation)
• Smoking, alcohol, IV drug use
• Sexual orientation and practices

Special Populations to Flag

• Neonates and elderly patients
• Chronic hepatic or renal failure
• Patients on glucocorticoids, NSAIDs, or anticytokine therapy (anti-TNF, anti-IL-1, anti-IL-6)

• Immunocompromised (HIV, chemotherapy, transplant)
• Returned traveler within 1 year
• Neonates (<28 days old)

Disease Categories That Present with Fever (Harrison's Table 20-1)

1. Infectious diseases (most common)
2. Autoimmune and noninfectious inflammatory disorders (SLE, vasculitis, Adult Still's disease, IBD)
3. Cancer (lymphoma, renal cell carcinoma, hepatocellular carcinoma, leukemia)
4. Medication-related (drug fever, vaccine reactions)
5. Endocrine (hyperthyroidism, adrenal insufficiency)
6. Intrinsic hypothalamic malfunction (rare)

Complete History for Admission to a Medicine Ward

1. Patient Identification (Biodata)

2. Chief Complaint (CC)

• A single, short sentence in the patient's own words stating the main symptom and its duration
• Include age, sex, and the presenting problem
• List multiple complaints in order of clinical priority if present

Example: "A 45-year-old male farmer presenting with high-grade fever for 5 days and yellowish discoloration of eyes for 2 days."

3. History of Present Illness (HPI)

• Was there a triggering event?
• Any prior episodes? If yes, what was diagnosed previously and what treatment was given?
• What treatment has been taken so far - home remedies, OTC medicines, consultation elsewhere?
• Response to any treatment already given
• Pertinent negatives - symptoms that are absent but help narrow the differential (e.g., "no cough, no burning urination, no joint pain")

Goldman-Cecil Medicine emphasizes: "Be careful to avoid 'premature closure' - when a diagnosis is assumed before all information is collected."

4. Past Medical and Surgical History (PMH/PSH)

Medical History

• Known chronic diseases: hypertension, diabetes mellitus, tuberculosis, asthma/COPD, epilepsy, thyroid disease, heart disease, renal disease, liver disease, HIV, malignancy
• Prior similar episodes and their diagnosed causes
• Hospitalizations in the past - where, when, for what
• Childhood illnesses (rheumatic fever, jaundice, measles)
• Recent infections or illnesses in the preceding weeks

Surgical History

• Previous operations - type, date, outcome
• Anesthetic complications
• Unexplained surgical or traumatic scars (ask if the patient does not volunteer)

Obstetric/Gynecological History (for women)

• Menstrual history: LMP, cycle regularity, dysmenorrhea
• Obstetric history: gravida/para/abortions (G/P/A)
• Contraceptive use (oral pills - relevant for thrombosis, drug interactions)
• Menopausal status

5. Drug History and Allergies

Drug History

• All current medications: prescriptions, over-the-counter drugs, vitamins, herbal/ayurvedic/homeopathic preparations, topical applications, eye/ear drops, inhalers
• For each drug note: name, dose, frequency, how long taken
• Recent antibiotics (alters cultures and sensitivity)
• Immunosuppressants, steroids (blunt fever and infection signs)
• Anti-cytokine therapy (anti-TNF, anti-IL agents - mask fever)
• Blood thinners (anticoagulants, antiplatelets - relevant before procedures)
• Any recently started or stopped medications

Allergy History

• Drug allergies: name the drug and the exact reaction (rash, anaphylaxis, vomiting - distinguish true allergy from intolerance)
• Food allergies
• Environmental allergies (dust, pollen)

Goldman-Cecil note: "Patients may attribute adverse reactions or intolerances to allergies, but many supposed allergic reactions are not truly drug allergies. Eliciting the actual response facilitates determination."

6. Family History (FHx)

• Health status of parents, siblings, and children (alive/dead; if dead, age and cause)
• Familial diseases especially relevant to the presenting complaint:
  • Cardiovascular: hypertension, coronary artery disease, stroke
  • Metabolic: diabetes mellitus, obesity, thyroid disease
  • Respiratory: asthma, TB contacts
  • Malignancy: type and age of onset
  • Neurological: epilepsy, migraine
  • Genetic/inherited: sickle cell disease, thalassemia, G6PD deficiency, haemophilia
  • Autoimmune/rheumatological: SLE, rheumatoid arthritis
  • Infectious: TB contact in family, HIV-positive family members
• Familial periodic fever syndromes in relevant ethnic groups (Familial Mediterranean Fever, TRAPS)

7. Personal/Social History

Habits/Substance Use (ask non-judgmentally)

• Tobacco: smoking (cigarettes, bidi, cigars, hookah) - type, quantity (pack-years), duration, quit date if applicable; smokeless tobacco (paan, gutka)
• Alcohol: type, quantity per day/week, duration; effect on social and work life; CAGE questionnaire if dependence suspected
• Recreational/illicit drugs: IV drug use (HIV, hepatitis, endocarditis risk), stimulants, opioids

Diet

• Vegetarian / non-vegetarian
• Dietary habits relevant to disease: raw meat (toxoplasma), unpasteurized dairy (brucella), freshwater fish (clonorchis)
• Nutritional status

Sexual History (where relevant)

• Sexual orientation and gender identity
• Number of partners, unprotected intercourse (STI risk, HIV, hepatitis B/C)
• Ask sensitively and in a non-judgmental manner

Occupational History

• Current and past occupations
• Exposure to chemicals, dusts, fumes, metals, radiation, animals
• Healthcare worker status (TB, hepatitis B, needle stick risk)

Travel History

• Recent domestic and international travel
• Exposure up to 1 year prior is relevant for some infections (malaria, leishmaniasis, typhoid)
• Destinations, duration, activities (freshwater exposure, jungle travel)

Living Conditions and Environment

• Urban vs. rural
• Overcrowding, sanitation, clean water access (cholera, typhoid, leptospirosis)
• Animals at home or nearby (zoonoses)
• Recent contact with sick individuals

Socioeconomic Status

• Education level (relevant for informed consent, health literacy)
• Insurance/financial status (affects treatment planning)
• Support systems: lives alone, caregiver available

Military History

• Veterans should be asked about combat, deployment area, and PTSD screening

8. Immunization History

• Childhood immunizations (BCG, OPV, Hepatitis B, DPT, MMR, etc.)
• Adult vaccines: influenza, pneumococcal, hepatitis A/B, typhoid, rabies, COVID-19
• Status of recent vaccines (relevant to vaccine reactions presenting as fever)

9. Review of Systems (ROS)

10. Summary Statement and Provisional Diagnosis

• Age, sex, background
• Duration and nature of presenting complaint(s)
• Key positive and negative findings from the history
• Most likely provisional diagnosis and important differentials to rule out

Example: "A 35-year-old male agricultural worker from a rural area presents with 7 days of high-grade fever with chills, jaundice, myalgia, and oliguria following flood exposure. Provisional diagnosis: Leptospirosis. Differentials: Malaria, Viral hepatitis, Dengue."

Key Principles to Remember

1. Open-ended questions first - let the patient tell their story; then ask specific follow-up questions to fill gaps
2. Pertinent negatives are as important as positives - they help exclude diagnoses
3. Chronological order - the story should flow as a timeline
4. Avoid premature closure - do not stop taking history once one diagnosis seems obvious
5. Reliability of informant - note if history is from a third party (unconscious patient, child, confused elderly person)
6. Consistency - verify key facts by asking in different ways
7. Sensitive topics (sexual history, drug use, psychiatric history) - ask last, in a private, non-judgmental setting