Candidates spend most of their time, when taking a history about fever, in determining whether the patient had rigors, how many times the fever rose or fell. Important points such as the presence of a prodrome, accompanying symptoms, and whether someone in the family or other contacts was ill are left behind. In one tutorial the candidate was asked to take a history of a 15-year-old man who had a fever for 4 weeks, become afebrile and a week later had the fever again. Seven minutes were alloted to the history taking.
The questions asked were: how long have you had the fever? Was it continuous? Was it there all the time? Did it rise or fall at any times? Did you check it with a thermometer? How much was it? Did it fall after a few hours? Was it always 102 or 103 degrees? Did it ever fall to normal? Did you have fever in the day and night? Did you have a rigor? You never had a rigor? Did you have evening rise of fever? Oh, you had fever all the time. It stayed 103 degrees most of the time but did you have a rigor? It was no worse in the evenings? When it settled did you have a lot of sweating? Did you go to a hospital? Were some tests done? Did you receive some treatment? (Did not ask what tests were done and what the tests showed., what the X-ray chest showed and what treatment was given and what was the name of the injections the patient received and what did the doctor tell you about the diagnosis). The patient volunteered that he had a cough. No further questions were asked about any other respiratory symptoms. By now the time was up.
What mistakes were made? Too many questions were asked about the fever. Once the patient had said that he had “fever all the time, it was 102 to 103 degrees by the thermometer” it was established that he had continuous fever for a month. Rigors do not occur in continous fever. With this degree of fever night sweats are unlikely. Move on. No questions were asked about a prodrome (Did you feel unwell a few days before you developed fever like aches and pain, headaches and poor appetite and lethargy?). Did you have a dry cough? If the answer is yes please do not ask “How much did you expectorate?” That is a no brainer. Sore throat, sneezing, watery eyes, wheezing and breathlessness are valid questions as is chest pain. Breathlessness may be a caused by bronchospasm or a developing pleural effusion or pulmonary edema from a myocarditis. Chest pain may be a clue to pneumonia, pleuritis or pericarditis. Ask about weight loss in one month. Ask if the joints hurt or were swollen. Severe arthralgia can occur in dengue fever, Chikangunia, Zika virus, SLE, early onset rheumatoid arthritis. Other infective causes of fever with arthralgia/arthritis are reactive arthritis, Echo and Coxsackie virus infections usually of the gut, Parvovirus specially Parvovirus 19, Epstein-Barr virus and rarely HCV, HBV and HIV. Ask about a rash. In many viral infections a rash accompanies the fever. Ask about diarrhoea and urinary symptoms.
The following information was obtained by the tutor who was conducting the tutorial.
This patient was aware that he had suffered from tuberculosis at the age of 18 months and had received 1 year of anti-TB therapy. His brother who accompanied him confirmed this. The doctors saw some shadows on the chest X-ray and initially thought of reactivated TB but the X-ray done after a week was clear so the diagnosis was changed. The young man received injection Novidat for 2 weeks and the fever settled. He knew that his platelets were not low but did not know what the blood culture showed. His father also fell ill with a fever and had to be hospitalised for a week and given Novidat injections too. He had no diarrhoea or joint pains or rash. A week after being discharged afebrile from the hospital he developed the fever and needed to be hospitalised again. He had lost 2 kg weight during the illness and knew this.The patient was a student of class 10 and had all this information but the candidate did not ask the right questions.
When you are taking a history please do not assume that the patient is too ignorant to answer your questions. You must ask about the details of investigations and treatment the patient has already received. Also ask what the previous doctors have told him about the disease and what he himself thinks about his illness. You are entitled to ask about the results of tests that have been done and can ask to see the results including the ECG, X-rays and ultrasounds and echocardiogram and blood tests that are available. A consultant never tries to diagnose a disease without looking at previous diagnostic results and treatments that the patient has received. As a candidate for FCPS II you are entitled to the same information. The most probable diagnosis in this patient was enteric fever from the salmonella group like typhoid, paratyphoid A and B, and non-typhoid salmonella.
- What would you look for in the GPE in this patient and in the systemic examination?
- What is likely to happen to his pulse?
- What can be seen in an ECG in typhoid fever?
- What other bacterial fevers would you think of?
- What would you test for if you think this patient has become a carrier for salmonella?
- How would you know if an intestinal perforation or hemorrhage has occurred?
- Does a rash occur in the enteric group of fevers?
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Please listen to the patient, understand what he says and take your cues for a diagnosis from there. Do not try to fit the patient’s history into a stereotype.
A 61-year-old man came to the hospital and was selected for a long case in the FCPS II exam. He was very vocal, alert and aware of his illness though only a matriculate. The history he gave was that he had been feeling unwell for two weeks with lethargy and aches and pains. Five days before admission he developed a discomfort in his head which he described as “heaviness”. His nephew brought him to the hospital and after examination the doctor admitted him and did some tests. He was told that his spleen was grossly enlarged and his white cell count was very high. He told the candidate this. The examiners thought that as the patient had almost told the candidate the diagnosis, the young doctor would move on from there and would talk about diagnostic advances, treatment, prognosis etc.
The candidate, on hearing this history, said “Do you have a fever?” the answer was a categorical no. The next question was “Have you had a fever recently?” the answer was that 4 months ago there was a fever for a week. The local GP told the patient that it was Chikangunya fever which was prevalent in the area. He was given ibuprofen and the fever subsided. The doctor gave him a saline drip for good measure. The candidate spent the next 10 minutes asking questions about the fever; the usual “Was there a rigor? how many times was there a rigor? How much was the fever? Were there night sweats? Did the fever occur in the night or the day? Was the temperature checked with a thermometer? Did he feel cold? Did he sweat when the fever fell? Was it a continuous fever? etc” Each question was repeated several times with the patient trying his best to remember the fever 4 months ago. Finally the patient lost his temper and said “Doctor I do not have a fever. You have asked me these questions 15 times and the answer is that I do not remember the fever 4 months ago. I do not have a fever now”. The candidate turned to the examiners and said “I cannot present this case as this patient is not co-operating with me”. On being asked what it was that he could not present, the answer was that he will not tell me about his fever. The examiner said why don’t you check his fever as he keeps saying that he has no fever. The candidate said “Then what am I to present?”.
One examiner said “Okay, I will take the history”. It turned out that in addition to the enlarged spleen and raised white cell count that the ER doctor had told him about he had suffered from profound tiredness. For 6 months he had given up his job and was being looked after by his nephew whom he had brought up as he had not married and had no children of his own. He had been distempering people’s houses to earn a living for 1 year. Before that he had been a professional cook working for a caterer and cooking large quantities of food (degh) for weddings. He earned good money but gave that up because he felt too tired to carry large sacks of rice and potatoes and the heavy iron pots. The occupational history gave a clear evidence of progressive weakness and tiredness sufficient to interfere with his life style and his earnings. He had lost his appetite and weight. On examination he was grossly anemic, looked emaciated, weighed 52 kg, had no lymphadenopathy and had a massive spleen. He had originally weighed 78 kg.
The young doctor was fixated on a history of fever because he only knew how to make sense of that, He did not realise that the social and occupational history can give clues to the diagnosis or progression of disease. This part of the history is often glossed over because the candidate does not understand the significance. If an elderly gentleman no longer goes to pray in the mosque ask why. He either gets tired or has angina or has ischemic pains in the legs. A middle-aged man has stopped walking to work and now takes a bus. Why? He may have angina or gets too tired. A house wife now gets her neighbour to do her groceries. A security guard asks for a desk job. Same reasons. So ask for a change in life style. It may be significant.
Remember every part of the history is significant. How significant depends on the situation. A change in the economic circumstances like loss of a job may mean that the family is living in crowded accomodations and TB becomes a risk. Poor food may mean anemia. Ask why someone has lost a job or changed a job. Practice taking a history of what you consider odd or unusual cases then you will not be caught unprepared
Swollen joints occur in rheumatic fever specially if the arthritis migrates from joint to joint, rheumatoid arthritis is a possibility if small joints are involved.