Fever in the Returned Traveler — Key Elements of History and Physical — Clinical Pathway: Emergency Department

Fever In the Returned Traveler — Emergency Department

Key Elements of History and Physical Exam

Returned travelers are at risk for infectious diseases that we may not frequently see in our practice. A thorough history and physical exam is important to determine risk factors for, and signs and symptoms of both cosmopolitan infections (e.g. urinary tract infection, pneumonia) as well as diseases related to travel.

History

History of Present Illness
  • Onset, duration, method of temperature measurement, height of fever
  • All associated signs and symptoms
  • Ill contacts
  • Current medications, including antipyretics and antimicrobials
  • Vaccination status
    • Includes routine and travel vaccines
    • e.g. Typhoid, Japanese encephalitis, Hepatitis vaccines, Yellow fever, Measles booster, Rabies
  • Pre-travel evaluation, prophylaxis and treatments given
  • Water source during travel
  • Medical illness and treatment during and since return from travel
  • Specific locations of travel
    • Urban vs rural, names of all cities/towns, include stop overs
  • Accommodations
    • Consider hotel, private home including type of dwelling, or camping
    • Bed net use, window screens, air conditioning
  • Activities during travel and purpose of trip
  • Unusual exposures
Physical Complaints and Exam Findings Some Diagnosis Considerations
General Toxic appearing Dengue, malaria, typhoid
Cachectic TB, Brucellosis, HIV/AIDS, cholera
HEENT Conjunctival pallor Dengue  , malaria
Periorbital swelling Chagas disease  
Scleral icterus Hepatitis, Yellow fever, leptospirosis
Conjunctivitis Leptospirosis, Zika, Measles  
Koplik spots Measles  
Angioedema Schistosomiasis
Lymph Focal lymphadenopathy Neck: TB (scrofula), African trypanosomiasis (Winterbottom’s sign)
Elsewhere: Typhoid, Tularemia, Filariasis
Generalized lymphadenopathy Acute HIV, Leptospirosis, Brucellosis, Dengue, Visceral leishmaniasis, Lassa fever, Syphilis
Lungs Focal or diffuse lung findings (crackles, decreased aeration, wheezing) Acute TB, MERS-CoV, Q fever, Hantavirus, Melioidosis, Loeffler syndrome, Leptospirosis, Pneumonic plague, Legionellosis, Diphtheria, Psittacosis
Cough TB, Filariasis, Schistosomiasis
Cardiovascular Relative bradycardia Typhoid (less frequently observed in children), dengue, typhus, leptospirosis, malaria
Murmur Subacute bacterial endocarditis, Chagas disease
Abdomen Abdominal tenderness/Pain Typhoid, Malaria, Liver abscess, Liver cyst(s) (Echinococcus), Cholangitis due to liver fluke, Hepatitis (RUQ pain), Schistosomiasis
Diarrhea
  • Bacterial Diarrhea (ETEC, EAEC, EIEC, Campylobacter, Shigella, Salmonella)
  • Viral diarrhea
  • Parasitic diarrhea – usually afebrile
    • (Giardia/Amebiasis/cyclospora)
  • Systemic Disease with GI symptoms e.g. malaria, typhoid (may also have constipation), GI tuberculosis
Hepatosplenomegaly Splenomegaly: Visceral leishmaniasis, Typhoid, Brucellosis
Hepatosplenomegaly: Acute HIV, Hepatitis, Katayama fever, Malaria, Leptospirosis, Amoebiasis
Ascites TB
Peritonitis Typhoid
Musculoskeletal Cystic nodules Cysticercosis
Arthralgias/Myalgias Schistosomiasis, Dengue, Chikungunya, Zika, Trichinellosis, Ross River virus, Muscular sarcocystosis
Neurologic Encephalopathy/Altered mental status Arboviruses (West Nile, Japanese encephalitis), Cerebral malaria, Typhoid, Rabies, African trypanosomiasis, Scrub typhus, Angiostrongyliasis, viral hemorrhagic fevers, Katayama fever
Meningismus Meningococcemia, African trypanosomiasis, amebic meningitis
Retro-orbital pain Dengue
Tremors/Ataxia African trypanosomiasis
Skin Eschar Rickettsial diseases (Scrub typhus, African tickbite fever),
East African sleeping sickness, West African sleeping sickness, Anthrax  
Jaundice Hepatitis, Yellow fever, Leptospirosis, Severe malaria, Severe dengue, Crimean-Congo hemorrhagic fever,
Other viral hemorrhagic fevers (i.e. Lassa, Ebola, Marburg), Oroya fever
Lymphangitis Nocardia, tularemia, Mycobacteria marinum, Leishmania brasiliensis, sporotrichosis, filariasis
Migratory lesions Cutaneous larva migrans  , Dracunculiasis, Fascioliasis, Gnathostomiasis, Hookworm, Loiasis, Paragonimiasis, Sparganosis, Strongyloidiasis
Pallor Dengue, Malaria
Petechia/Purpura/Ecchymoses Dengue, Leptospirosis, Meningococcemia, Rickettsial infections, Viral hemorrhagic fevers
Rash
  • Rose spots:
    • Enteric fever (typhoid)

  • Pruritic papules:
    • Swimmer’s itch  , Seabather’s eruption,
    • Hot tub folliculitis (Pseudomonas aeruginosa), Onchocerciasis

  • Nodules:
    • Echinococcus, Dirofilariasis, Cysticercosis, Toxocariasis,
    • Cutaneous leishmaniasis, Onchocerciasis, Mycobacteria, Nocardia, Bartonella

  • Diffuse maculopapular rash
    • Acute Hepatitis B, Coccidioidomycosis, Dengue, Leptospirosis, Louse bourne typhus, Measles  ,Rubella, Acute HIV, Rickettsial diseases, Syphilis, Yellow fever
Ulcer Anthrax, Chancroid, Diphtheria, Granuloma inguinale, Leprosy, Lymphogranuloma venereum, Melioidosis, Mycetoma, Mycobacteria, Plague, Pyoderma, Rickettsial infections, Syphilis Tropical Ulcer, Tularemia, Yaws, Amebiasis, Leishmaniasis  
Urticaria Schistosomiasis, Strongyloidiasis