One Question That Can Change the Diagnosis: Why Travel History Matters

A college student presents to the emergency department with fever, nausea, vomiting, and diarrhea after returning from a spring break humanitarian mission trip to Haiti. During the nursing assessment, the patient reports having brushed their teeth with water that might have been untreated and recalls receiving multiple mosquito bites. What might at first appear to be a routine case of gastroenteritis comes in this case with concern for dengue, malaria, typhoid fever, or cholera. The patient’s travel history changes not only the differential diagnosis but also the urgency of testing, treatment, and infection-control decisions.

One simple question can change a patient’s outcome: Have you traveled recently? According to the CDC, nearly half of travelers to low- and middle-income countries become ill during or after travel. Although many illnesses are mild, some require hospitalization, and others may not become apparent until weeks or even months after returning home. Some syndromes can present years after travel.

Why travel matters.

According to the WHO, international travel is on the rise. Millions of people are traveling for professional, personal, and humanitarian reasons. International travel exposes people to infectious diseases that may be uncommon in the United States. Contaminated food and water, insect bites, animal exposures, health care encounters abroad, inadequate hygiene practices, and close contact during travel can all increase the risk of infection. Because these illnesses often present with nonspecific symptoms, obtaining a travel history should be part of every initial assessment.

Evaluating ill patients with a recent travel history.

The CDC recommends using a syndromic approach when evaluating ill travelers. Rather than focusing on a specific disease, nurses should first identify the patient’s primary clinical syndrome—such as fever, respiratory symptoms, gastrointestinal illness, neurologic symptoms, skin manifestations, or eosinophilia—which can help narrow the differential diagnosis and guide appropriate diagnostic testing.

Imported infections such as dengue, malaria, measles, and chikungunya may initially present with symptoms that resemble more common illnesses. Without a travel history, clinicians may not immediately consider these diseases. For example, missing a recent travel exposure can delay the diagnosis of malaria, a medical emergency that can rapidly become life threatening. Likewise, failing to recognize possible measles or viral hemorrhagic fever exposure could delay required isolation precautions and increase transmission risk.

Travel-related illness is not limited to international destinations. Domestic travel may expose patients to regional infections such as Lyme disease, hantavirus, valley fever, or mosquito-borne illnesses, depending on location and season.

The role of nurses.

Nurses play an important role in identifying illnesses that are associated with travel because they often perform the initial assessment, including asking questions about symptoms and potential exposures. A key part of that assessment is identifying potential travel-related exposures. Asking about travel history should be as routine as asking about medications or allergies. Nurses can use a simple framework to guide their assessment: “Where, When, What, and Who.”

Where did the patient travel? (Consider destinations, regions visited, and whether travel occurred in areas with known health risks.)

When did travel occur? (Consider dates of travel and symptom onset, including the incubation period of potential infections.)

What activities and exposures occurred? (Ask about food and water sources, mosquito or animal exposures, recreational activities, health care exposures, and whether recommended travel vaccines or preventive medications were received.)

Who else became ill? (Determine whether travel companions, family members, or others with similar exposures developed symptoms.)

These questions can uncover important details that may otherwise be missed.

Patient education is equally important. Before international travel, patients may need to consult a travel medicine provider or review CDC travel recommendations to determine whether vaccines, malaria prophylaxis, or other preventive measures are indicated. Nurses should reinforce safe food and water practices, mosquito bite prevention, and the importance of carrying needed medications rather than purchasing them abroad, where counterfeit products may be common. Prevention and awareness are the most effective strategies to avoid severe illness during travel.

Moving forward.

With billions of international trips occurring annually, clinicians are increasingly likely to encounter patients with travel-associated illnesses. A simple travel history can narrow the differential diagnosis, guide diagnostic testing, prompt timely isolation precautions, and improve patient outcomes.

Missy Travis, RN, MSN, CIC, FAPIC, is the founder of IP&C Consulting, LLC, a consulting business that supports infection preventionists, health care organizations, business owners, and professional sports teams in developing and sustaining effective infection prevention programs.