NMS Q&A Family Medicine

Travel Medicine 287and weakness. HACE symptoms and signs consist ofundue drowsiness, unsteadiness, irritability, hallucinations,and neurologic focal symptoms and signs.11. The answer is B. Furosemide would not be appropriatein this patient who has HAPE. The pulmonary edemais not due to passive congestion as in congestive heart failurewith significant hypervolemia. Rather, it is caused byporosity of the alveolar capillary bed, caused by relativehypoxia. The man lives at sea level and should have takena day or more to accommodate to 11,000 ft (3,353 m) ofaltitude before embarking and physically exerting on ahike to yet a higher altitude. His youth in itself is not anadvantage in the avoidance of HAI. Not only wouldremaining at 11,000 ft or 3,353 m have allowed him toacclimatize, but the resting period of a day would also initself make him more resistant to altitude sickness. Acetazolamideis a first-line drug; rapid descent is always a goodidea, if it is possible, then oxygen therapy and a hyperbarictent are effective, if available, and if all else fails andthe situation becomes urgent.12. The answer is C. Height of 10,000 ft (3,048 m) is thealtitude limit for normal passenger conveyance in unpressurizedaircraft, a safe altitude for this patient. Above thatlevel, oxygen supplementation must be supplied. However,this patient need not have oxygen throughout thetrip unconditionally any more than any other person.Above 10,000 ft or 3,048 m, oxygen should be supplementedat increasing concentrations for all passengersand for the pilot. At 20,000 ft (6,096 m), supplementaloxygen must be given at 100% concentration. At 40,000 ft(12,192 m), oxygen must be applied under pressureexceeding the atmosphere. In commercial travel, the foregoingare effected by cabin pressurization.13. The answer is D. Up to 5,000 ft (1,524 m) is supposedlythe maximum cabin pressure encountered in commercialpressurized aircraft. In practice, some probablywill go as high as 8,000 ft (2,438 m; equivalent to thatfound at Machu Picchu) but never more.14. The answer is B. Influenza vaccination is recommendedin the period of 1 to 3 months before travel toevery developing country. Td immunization is also recommendedto be current before travel to these countries,but one may be current for up to 10 years before travel, aslong as the person has not had a skin wound in the countrywhen the Td booster was last given more than 5 yearspreviously.15. The answer is C. Secretory otitis media of flight (aerotitismedia) can be prevented if the patient is able to forceair into the middle ears through the Eustachian tube(“clear the ears”) during descent by the modified Valsalvamaneuver. Naturally, this presupposes that the underlyingcause (e.g., viral upper respiratory tract infection or atopicsymptoms) is not so severe as to preclude this preventivemeasure, wherein the Eustachian tube may be so obstructedeven before descent in flight that it cannot be opened.Thus, barotitis in flight occurs most frequently duringdescent. Bacterial organisms are not involved in barotitismedia. The physical evidence of this form of secretory otitismedia is a retracted tympanic membrane seen at otoscopy.This entity occurs during scuba diving, likewiseduring descent, but the definitive treatment is simply toreturn to the surface, along with clearing the ears.16. The answer is B. The Indian subcontinent (bothIndia and Pakistan), still considered to be underdeveloped,is the one region mentioned among the choiceswhere typhoid vaccination is recommended. On the contrary,Canada, Europe, Australia, and New Zealand areamong the very few regions of travel for which typhoidvaccination is not recommended. Examples of othercountries that present significant risk of typhoid fever areall of Latin America, all of Africa, all of Asia and India; inshort, all countries except for all of western Europe, theUnited States, Canada, Australia, and New Zealand. Recommendedpretravel immunizations change from year toyear and destination to destination and too voluminousfor this work. They are best tracked by consulting theCDC web site, http://www.cdc.gov/nip.17. The answer is D. Paradoxical hypovolemia in the faceof fluid retention plays a significant part in the pathophysiologyof jetlag. Rapid east-to-west travel often results indifficulty in staying awake appropriate to the local time,whereas west-to-east travel results in sleep onset relativeto the local time at destination (the opposite to the statementsas presented in the question). Anti-jetlag diets havenot proven effective in preventing jetlag symptoms. Cabinaltitudes of 8,000 ft (2,438 m) for prolonged periods mayplay a significant part in the pathophysiology. Resting in aseat at 5,000 ft (1,524 m), the altitude of Denver, has littleeffect on healthy persons.18. The answer is E. Only a malarial smear, among thoseitems mentioned, should be checked for in an asymptomaticreturning traveler who had been to a tropical location.All the others are aimed at symptomatic conditions,except for tuberculosis. In the latter case, although conversionmay occur without symptoms, we recommendskin testing only in symptomatic cases. The only hepatitidesto be acquired in travel are A and E, neither of whichcauses chronic disease and need not be screened for in theabsence of symptoms.19. The answer is B. A 62-year-old African-Americanmale with nocturnal dyspnea and orthopnea should be