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Fever and rash in the returning traveler should prompt blood cultures and various serologic tests based on the exposure history The work-up of a pulmonary infiltrate should include the placement of a PPD, examination of sputum for acid-fast bacilli and possibly for ova and parasites Patients with evidence of meningoencephalitis should receive lumbar puncture, blood cultures, thick/thin smears of peripheral blood, history-guided serologies, and a nape biopsy (if rabies is suspected) Jaundice in a returning traveler should be evaluated for hemolysis, and the following tests should be performed: liver function tests, thick/thin smears of peripheral blood, and directed serologic testing The work-up of traveler s diarrhea is presented in the following section Finally, patients with fever but no localizing signs or symptoms should have blood cultures performed Routine laboratory studies usually include complete blood count with differential, electrolytes, liver function tests, urine analysis, and blood cultures Thick and thin peripheral blood smears should be done (and repeated in 12 24 hours if clinical suspicion remains high) for malaria if there has been travel to endemic areas Other studies are directed by the results of history, physical examination, and initial laboratory tests They may include stool for ova and parasites, chest radiograph, HIV test, and specific serologies (eg, dengue, leptospirosis, rickettsial disease, schistosomiasis) Bone marrow biopsy to diagnose typhoid fever could be helpful in the appropriate patient

Again, make sure there is an order-relevant billing type assigned to the partial settlement sales document type The SAP standard uses the partial settlement document type R3 and the associated order related billing type B3 Be sure to indicate that the system must reverse the accruals This will ensure the system will reverse the accruals up to the amount specified in the manual payment Should the accruals not be as high as the payment to be made, the system will reverse whatever accruals it has In the final settlement area, you must ensure the credit memo request for final settlement is assigned to the final settlement field (Again, be sure that this credit memo request has the associated order-relevant billing type assigned to it in the sales document type) The SAP standard uses the credit memo request B1 with billing type B1 One may also assign a minimum status, which is the status the rebate agreement must reach before the final settlement may be carried out

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The differential diagnosis of fever in the returning traveler is broad, ranging from self-limited viral infections to life-threatening illness The evaluation is best done by identifying whether a particular syndrome is present, then refining the differential diagnosis based on an exposure history The travel history should include directed questions regarding geography (rural versus urban), animal or arthropod contact, unprotected sexual intercourse, ingestion of untreated water or raw foods, historical or pretravel immunizations, and adherence to malaria prophylaxis

The most common infectious causes of fever excluding simple causes such as upper respiratory infections, bacterial pneumonia and urinary tract infections in returning travelers are malaria (see 35), diarrhea (see next section), and dengue (see 32) Others include respiratory

Freedman DO et al; GeoSentinel Surveillance Network Spectrum of disease and relation to place of exposure among ill returned travelers N Engl J Med 2006 Jan 12;354(2):119 30 [PMID: 16407507] Owen CE et al African tick bite fever: A not-so-uncommon illness in international travellers Arch Dermatol 2006 Oct; 142(10):1312 4 [PMID: 17043186] Ryan ET et al Illness after international travel N Engl J Med 2002 Aug 15;347(7):505 16 [PMID: 12181406] Stienlauf S et al Epidemiology of travel-related hospitalization J Travel Med 2005 May Jun;12(3):136 41 [PMID: 15996442]

Avoidance of fresh foods and water sources that are likely to be contaminated is recommended for travelers to developing countries, where infectious diarrheal illnesses are endemic

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