With the rise in the incidence of travel-related infectious diseases, people traveling abroad are at a high risk of health problems. Zika is the latest in the list of travel-related health diseases. The History and Physical exam (H&P) has become a critical component in the treatment of returned travelers who present with fever or disease. Even otherwise, admitting H&P forms a central part of the medical transcription task.
Evaluating the Returned Traveler
The Centers for Disease Prevention and Control recommends that when evaluating a returned traveler who is unwell, the physician should focus on identifying infections that are rapidly progressive, treatable, or transmissible. Public health officials need to be alerted if the condition is contagious and poses a health risk.
One of the main problems with patients who return unwell is that they may have been exposed to conditions that the physician is not familiar with or even not aware of. Therefore, history taking must include questions pertaining to the following aspects:
- Probable cause of the disease, which will depend on area of travel as well as risk-taking behavior and conditions encountered
- Nature, onset, and duration of symptoms
- Travel departure and return dates
- Area of travel to understand exposure to disease
- Duration of visit as risk increases with longer stay
- Purpose of travel – risk of infectious diseases is higher for emergency relief workers and healthcare workers
- Behavior and lifestyle of traveler and extent of contact with the local population
- Whether any known disease contacts or known insect or animal bites, scratches or licks
- Injuries or illnesses including treatment modalities – injections, blood taken or transfused, and surgery
- Unprotected intercourse
- Diet during travel/visit
- Vaccination history
A detailed history that extends beyond a few months before presentation is important for diseases such as tuberculosis as they can manifest several months later.
The degree of detail in a history and physical examination would depend on the nature and complexity of the patient’s condition. Accurate and timely transcription of the medical record can help physicians quickly review the patient’s medical history at repeat visits and add on to it.
Professional Medical Transcription Services for Reliable and Timely H&P Reports
A professional medical transcription company provides invaluable support for physicians with accurate and timely transcripts pertaining to the history and physical exam. The transcribed medical records would help the physician quickly review the patient’s medical history and proceed with diagnosis and treatment. In established companies, trained and experienced medical transcriptionists document the dictated reports accurately and legibly. Dedicated infectious diseases transcription service would certainly prove very useful for physicians evaluating and treating the returned traveler.
