History: Fever in a Returned Traveller

This is a common scenario and a wide range of differentials need to be ruled out. Good, precise history taking skills can narrow down the differential significantly.

OSCE scenario: This 36 year old lady has presented to A+E with a fever. She has returned from West Africa 5 days ago. Please take an appropriate history. 

• Symptoms – clarify exactly what symptoms the patient has had
• Fever:
• Any patterns to the fever, e.g. cyclical?
• Have they measured it?
• Organ-specific symptoms:
• Respiratory – SOB, cough, chest pain, haemoptysis
• Abdominal – diarrhoea, vomiting, abdominal pain, constipation
• GU – dysuria, frequency, haematuria
• Neurological – neck stiffness, headaches, seizures
• Skin – localised rash, erythema, swelling 
• Other important symptoms:
• Generalised rash
• Weight loss
• Night sweats
• Bleeding

• Timing of symptoms– this is extremely important as you can work out the probability of certain infectious diseases based on the incubation periods
• Onset – exactly when did the symptoms start?
• What was the course of the symptoms e.g. prodrome, relapsing, progressive
• Duration

• Travel history – this gives you an idea of their exposure to certain infectious diseases
• Which countries?
• Urban/rural environment
• Types of accommodation
• Dates of entering each country/returning home

• Risk factors – there are many possible risk factors that need to be asked about, an easy pneumonic to help you get through them quickly is SPACES
• Sexual
• Sexual intercourse whilst away?
• If so needs full sexual history
• Procedures
•  Any hospitalisation
• Any blood products received
• Any vascular access lines
• Piercings
• Intravenous drug-use
• Animal contact
• Any bites received (animals or insects)
• Close household contact with animals
• Contacts
• Any close contacts also unwell?
• Known diagnosis? Treatment?
• Eating & drinking
• Did they eat any high-risk foods e.g. street meat, unpasteurised milk,
• Did they drink unsterilized water?
• Swimming
• Any swimming in natural lakes/rivers
• Any activity involving water e.g. white water rafting, canoeing

• Prevention – how protected were they against disease:
• Vaccinations up to date
• Malarial prophylaxis (and compliance – did they complete the full course?)

• HIV – when was their last test and what was the result?
• Any previously treated infectious diseases (including malaria)?
• Any other chronic conditions (e.g. diabetes mellitus, malignancy)

• Immunosuppressants
• Antiretroviral therapy
• Antimalarials – which ones?
• Recent chemotherapy

• HIV
• TB
• Malaria

• Smoker (increased risk of respiratory infections)
• Alcohol
• Intravenous drug use
• Living situation ­– this is useful to know if you need to do contact tracing and also to understand support network
• How many people live with?
• Shared bathroom/kitchen?
• Dependants?

There are a huge number of weird and wonderful infectious diseases that could be causing the fever but don’t forget about the COMMON causes of a fever, e.g. pneumonia, UTI, influenza.

The list of differentials for infectious causes are listed below. Many of them have a wide incubation period, but their most common time of presentation is listed.  Incubation times can really help you with your diagnosis and are important to know. For example if the fever has presented < 7 days after exposure then malaria can be ruled out. The incubation period of malaria  is typically 7 days – 3 months, but can be even longer in P. vivax and P. ovale subtypes).

The important, common diagnosis in a returned traveller are highlighted in bold.

• www.uptodate.com/contents/evaluation-of-fever-in-the-returning-traveler
• Oxford Handbook of Tropical Medicine

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