Eduovisual
Multisystem Processes & Disorders
Refugee and immigrant health screening
— Refugee: person outside country of nationality unable to return due to persecution; granted status before US arrival
— Asylee: similar persecution criteria but applies from within US
— Special Immigrant Visa (SIV): Iraqi/Afghan allies; eligible for same domestic medical exam as refugees
— Immigrant: broader term; includes documented and undocumented arrivals
— Overseas medical exam (panel physician, CDC-directed): TB screening, syphilis, gonorrhea, vaccines, mental health screen; results in DS-2053/DS-3025 forms
— Domestic refugee health assessment within 30–90 days of US arrival (ORR funds; varies by state, often Medicaid-billed)
— Recent arrival (<5 years) from high-prevalence region
— Symptoms compatible with latent TB, hepatitis B, parasitic infection, Chagas, strongyloidiasis, schistosomiasis
— Incomplete or missing vaccination records
— Mental health complaints with trauma history (torture, war, trafficking)
— Unexplained eosinophilia, anemia, hematuria, or chronic GI symptoms
— Use the visit to layer acute care + catch-up preventive care + culturally competent counseling
— Engage trained medical interpreter (not family); document interpreter ID number
— Address social determinants: housing, food security, legal status, employment authorization
Step 3 management: When a newly arrived refugee presents to your clinic and the 30–90 day domestic exam has not yet occurred, schedule it promptly rather than deferring — this single visit drives TB, HBV, parasite, lead, vaccine, and mental health screening simultaneously and is fully reimbursable under ORR/Medicaid. Do not assume the overseas exam covered chronic disease screening; it did not.
Board pearl: Eosinophilia >450/µL in a newly arrived refugee from Africa, Asia, or Latin America is parasitic until proven otherwise — empiric albendazole + ivermectin is often part of presumptive treatment protocols.
— Sub-Saharan Africa: schistosomiasis, strongyloides, malaria, HIV, HBV, sickle cell trait, FGM/C history
— South/Southeast Asia: TB, HBV, strongyloides, intestinal helminths, thalassemia, G6PD
— Latin America: Chagas (T. cruzi), strongyloides, cysticercosis, HTLV-1, dengue exposure
— Middle East/Afghanistan: cutaneous leishmaniasis, TB, brucellosis, vitamin D deficiency, lead exposure
— Eastern Europe/Ukraine: MDR-TB, HIV, HCV, diphtheria gaps, radiation exposure history
— Country of origin, transit countries, time in refugee camps
— Prior trauma: torture, sexual violence, child soldier exposure, witnessing death
— Prior medical care access, medication history, immunizations received
— Length of transit, conditions, water/food sources
— Sexual assault during journey (especially women, unaccompanied minors)
— Injuries, untreated fractures, dental neglect
— Housing stability, overcrowding (TB transmission risk)
— Employment, school enrollment, English proficiency
— Family separation status, immigration legal status
— Somatic complaints often proxy for psychological distress (headache, abdominal pain, "all-over pain")
— Idioms of distress: ataque de nervios, khyâl, susto — do not dismiss as malingering
— Ask about traditional remedies, herbal medications, coining/cupping (can mimic abuse on exam)
Key distinction: A family member should not interpret, especially for sensitive topics (sexual violence, mental health, reproductive care). Use a certified medical interpreter — phone or in-person — and document. Failure is both a quality and a legal/HIPAA issue.
Board pearl: Always ask "Were you ever separated from family during your journey?" — this single question screens for trafficking, unaccompanied minor status, and trauma exposure simultaneously.
— Plot height, weight, BMI, and head circumference (<2 yr) on CDC charts; many children show stunting
— Cachexia, muscle wasting → chronic infection, malnutrition, malabsorption
— Dental caries, gingivitis nearly universal — refer dental
— Scars from torture: linear lash marks, cigarette burns, electrical burn pattern, suspension marks at wrists/ankles
— Cutaneous leishmaniasis: ulcerated nodule with raised border, often face/extremities
— Onchocerciasis: depigmented patches, nodules, pruritus (Africa)
— Coining/cupping marks: linear erythema/petechiae — cultural, not abuse
— BCG scar on deltoid → prior vaccination, does not invalidate TST/IGRA
— Visual acuity, untreated strabismus, vitamin A deficiency (Bitot spots)
— Hearing loss from untreated otitis or ototoxic antibiotics
— Goiter (iodine deficiency endemic areas)
— Rheumatic heart disease murmurs (mitral stenosis especially) — common in young adults from endemic regions
— Chronic cough → TB workup mandatory
— Hepatosplenomegaly: malaria, schistosomiasis, visceral leishmaniasis, chronic HBV
— FGM/C exam (female genital mutilation/cutting): document type I–IV using WHO classification; ask about urinary/menstrual/sexual symptoms; never re-infibulate
— PTSD signs: hypervigilance, flat affect, dissociation during exam
— Focal deficits → consider neurocysticercosis, prior stroke, untreated epilepsy
Step 3 management: When examining survivors of torture or sexual violence, announce each step before touching, allow a same-gender chaperone, and offer to defer the genital exam to a follow-up visit. Building trust over multiple visits yields better screening completion than forcing a comprehensive first-visit exam.
Board pearl: A BCG scar does not invalidate IGRA (QuantiFERON, T-SPOT) and IGRA is preferred over TST in BCG-vaccinated adults to avoid false positives.
— CBC with differential — anemia, eosinophilia (>450 triggers parasite workup), thrombocytopenia
— Comprehensive metabolic panel — baseline renal/hepatic
— Hemoglobinopathy screen if anemic or from endemic area (electrophoresis)
— Urinalysis — hematuria → schistosomiasis (S. haematobium); proteinuria → chronic disease
— Lead level in all children <16 (overseas exposure plus US housing); repeat 3–6 months after arrival
— Vitamin D, B12 in high-risk groups (veiled clothing, vegetarian diets, Afghan/Somali populations)
— TB: IGRA preferred (BCG-vaccinated); TST acceptable in children <5; CXR if symptomatic or positive IGRA
— HIV: 4th-gen Ag/Ab — all ages including children
— Hepatitis B: HBsAg, anti-HBs, anti-HBc triple panel (determine infection, immunity, or susceptibility)
— Hepatitis C: anti-HCV all adults (USPSTF universal); confirm with HCV RNA
— Syphilis: treponemal or non-treponemal; reverse algorithm acceptable
— Gonorrhea/chlamydia: sexually active or trauma history
— Strongyloides serology — universal for refugees from endemic areas
— Schistosoma serology — sub-Saharan Africa
— Trypanosoma cruzi serology — Latin American adults (Chagas)
— Malaria: thick/thin smears if symptomatic or from sub-Saharan Africa within 3 months
— Ova and parasites ×3 if eosinophilia, GI symptoms, or no presumptive treatment given
— Giardia antigen if diarrhea
CCS pearl: Order the screening panel as a bundle on the initial visit, schedule follow-up at 2 weeks to review, and pre-book a third visit at 6 weeks for vaccine catch-up and lab repeats. This three-visit cadence is the highest-yield CCS approach for a refugee health case.
Board pearl: Microscopic hematuria in a refugee from sub-Saharan Africa = schistosomiasis until proven otherwise — order serology and treat with praziquantel.
— Positive IGRA → CXR to rule out active TB
— CXR abnormal or symptomatic → 3 sputum AFB smears + cultures + NAAT; isolate
— CXR normal + asymptomatic = latent TB infection (LTBI) → treat
— Children <5 with positive TST/IGRA → always treat, even without CXR findings, after ruling out active disease
— HBsAg+ → HBeAg, anti-HBe, HBV DNA, ALT, hepatitis D Ab, HCC screening with US + AFP every 6 months if cirrhotic or high-risk demographics (Asian men >40, African >20)
— Vaccinate all household contacts and sexual partners
— Positive strongyloides serology → treat with ivermectin 200 mcg/kg ×1–2 days (avoid steroids until treated — hyperinfection risk!)
— Schistosoma serology+ → praziquantel 40 mg/kg single or divided dose
— Chagas serology requires two different assays for confirmation; positive → echocardiogram, ECG, GI evaluation
— Refugee Health Screener-15 (RHS-15) validated tool for depression/anxiety/PTSD
— PHQ-9, GAD-7 in translated versions
— Positive screen → warm handoff to behavioral health, not just referral
— Children: developmental screening (ASQ), Denver II, lead repeat, dental
— Newcomer school readiness assessment for educational placement
— Pap smear per USPSTF (age 21+, every 3 years)
— Pregnancy test, contraception counseling, prenatal labs if pregnant
— FGM/C documentation, defibulation counseling if indicated
Step 3 management: Before starting corticosteroids, biologics, or chemotherapy in any patient born in a strongyloides-endemic region, screen with serology and empirically treat with ivermectin — disseminated strongyloidiasis carries >80% mortality and is a classic Step 3 "avoidable death" question.
Key distinction: Anti-HBc alone (isolated core antibody) suggests occult HBV or resolved infection; check HBV DNA before immunosuppression.
— Tier 1 (same-day action): active TB symptoms, acute malaria, suicidal ideation, acute trafficking disclosure, untreated HIV with low CD4, pregnancy in third trimester without prenatal care
— Tier 2 (within 1–2 weeks): LTBI treatment initiation, HBV confirmation, parasitic treatment, vaccination start, dental pain
— Tier 3 (routine/longitudinal): chronic disease screening, cancer screening catch-up, developmental assessment
— CDC recommends pre-departure presumptive treatment for many refugees:
— Albendazole (soil-transmitted helminths) — most regions
— Ivermectin (strongyloides) — most regions except Loa loa endemic (risk of fatal encephalopathy)
— Praziquantel (schistosomiasis) — sub-Saharan Africa
— Antimalarials for sub-Saharan African refugees
— Verify on DS-3025 form; if not given, provide post-arrival
— Refugees from Central/West Africa (Cameroon, Nigeria, Gabon, DRC, etc.) require Loa loa screening before ivermectin (microfilaria count); high counts cause fatal encephalopathy
— Adults need MMR, Tdap, varicella, HPV, influenza, COVID, hepatitis B; pneumococcal/zoster age-based
— Tetanus high-risk in refugees with prior wounds — give Tdap promptly
— Use CDC catch-up schedule; serology to confirm immunity acceptable
— Diabetes, hypertension, hyperlipidemia screening per USPSTF
— Smoking, alcohol, betel nut, khat counseling
CCS pearl: Place orders as "screening bundle," "vaccinate today," "counsel — interpreter," and "behavioral health referral" in parallel rather than serially. Advance the simulated clock by 2 weeks to review results; CCS rewards efficient parallel ordering.
Board pearl: Never give ivermectin empirically to a refugee from Loa loa endemic regions without screening — fatal encephalopathy is a tested complication.
— 3HP: isoniazid + rifapentine weekly × 12 weeks (DOT or self-administered); preferred for ≥2 years old
— 4R: rifampin daily × 4 months — good option, lower hepatotoxicity than INH
— 3HR: isoniazid + rifampin daily × 3 months
— 6–9 months INH still acceptable but lower completion
— Check baseline LFTs; monitor if symptoms, alcohol use, HIV, pregnancy
— Ivermectin 200 mcg/kg PO daily × 2 days (some protocols single dose)
— Recheck serology at 6–12 months; titer should fall
— Praziquantel 40 mg/kg PO (single or split same-day doses); 60 mg/kg for S. japonicum/mekongi
— Albendazole 400 mg PO ×1 (or ×3 days for strongyloides backup, hookworm heavy)
— Benznidazole 5–7 mg/kg/day × 60 days (first-line; access via CDC)
— Nifurtimox alternative; treat all <50 yr and consider in older without advanced cardiomyopathy
— Treat if meets AASLD criteria (HBV DNA + ALT + fibrosis): entecavir or tenofovir (TDF/TAF)
— Direct-acting antivirals (sofosbuvir/velpatasvir or glecaprevir/pibrentasvir) — pangenotypic, 8–12 weeks
— Uncomplicated P. falciparum: artemether-lumefantrine
— P. vivax/ovale: chloroquine + primaquine (check G6PD first!)
Step 3 management: Before starting primaquine or tafenoquine for vivax/ovale radical cure, always check G6PD status — hemolysis in G6PD-deficient patients is a classic Step 3 medication-safety vignette.
Board pearl: 3HP (isoniazid + rifapentine) is the preferred LTBI regimen for refugees because shorter duration dramatically improves completion rates — a value-based, public-health-aligned answer.
— Accept written records only; oral history insufficient except influenza/PCV
— Serology to document immunity acceptable for: MMR, varicella, hepatitis A, hepatitis B
— Required for adjustment of status (green card): MMR, Td/Tdap, varicella, polio, HBV, influenza (seasonal), pneumococcal (age-based), COVID, rotavirus/Hib/PCV (pediatric)
— MMR: 2 doses ≥28 days apart for adults without immunity
— Varicella: 2 doses 4–8 weeks apart if no history/serology
— HPV: ages 9–26 routine; shared decision 27–45
— Hepatitis B: 3-dose series or Heplisav-B (2 doses)
— Tdap: 1 dose adults, then Td/Tdap every 10 years; Tdap in every pregnancy 27–36 weeks
— Polio (IPV): complete series if undocumented
— Meningococcal: college students, asplenia, complement deficiency
— Use CDC catch-up schedule by age; combination vaccines minimize visits
— BCG documented overseas does not replace any US vaccine
— PrEP (emtricitabine/tenofovir) for HIV-negative at risk
— Folic acid for women of reproductive age
— Vitamin D supplementation common in veiled women, dark-skinned individuals in northern latitudes
— Iron for anemia confirmed by ferritin
— Refugees often visit relatives back home (VFR travelers) — highest risk for malaria, typhoid
— Provide malaria chemoprophylaxis, typhoid vaccine, hepatitis A
— Remind that prior immunity wanes; VFR travelers underestimate risk
CCS pearl: On a CCS case, order "administer vaccines" at the first visit when serology is negative, and counsel patient — vaccination, interpreter simultaneously. Don't wait for all serologies before starting catch-up; you can vaccinate during workup.
Board pearl: VFR travelers (Visiting Friends and Relatives) are the single highest-risk group for imported malaria in the US — always screen pre-travel.
— Often have untreated chronic disease accumulated over decades: HTN, T2DM, COPD from biomass smoke exposure, osteoporosis
— Polypharmacy risk when added to existing herbal regimens
— Cognitive screening complicated by language/literacy — use RUDAS (Rowland Universal Dementia Assessment Scale) designed for multicultural populations rather than MMSE/MoCA
— Depression prevalence high — losses, displacement, role reversal in family
— Falls risk: vitamin D deficiency, sarcopenia, untreated visual impairment
— Colonoscopy/FIT for age 45–75
— Mammography 40/50–74 per shared decision
— Cervical cancer rates often higher (unscreened HPV); Pap + HPV co-testing
— Lung CT screening if eligible by smoking history (biomass exposure not currently included in criteria but document)
— Many drugs require dose adjustment: albendazole generally safe; praziquantel safe; ivermectin no adjustment; TDF avoid in CKD — use TAF or entecavir for HBV
— Contrast and iodine load caution in goiter
— Common in HBV/HCV/schistosomiasis-associated periportal fibrosis
— Avoid INH-containing LTBI regimens in decompensated cirrhosis — use rifampin alone with hepatology input
— Praziquantel safe in compensated disease
— Screen for HCC every 6 months with US + AFP if cirrhotic
Step 3 management: In an elderly refugee with new-onset cognitive complaints, screen for B12 deficiency, hypothyroidism, depression, vitamin D, and syphilis (RPR) in addition to standard dementia workup — reversible causes are disproportionately common.
Key distinction: TAF and entecavir are preferred over TDF in older patients with reduced bone density or eGFR <60 — a frequent prescribing nuance in HBV management.
— Confirm pregnancy at first visit; initiate prenatal care immediately
— Screen: HIV, syphilis, HBV (HBsAg), HCV, GC/CT, rubella immunity, varicella, TB (IGRA), urine culture, GBS at 36 weeks
— Vaccines safe in pregnancy: Tdap, influenza inactivated, COVID, hepatitis B; avoid live (MMR, varicella) until postpartum
— HBsAg+ mother: infant gets HBIG + HBV vaccine within 12 hours of birth; monitor maternal HBV DNA — antiviral (tenofovir) in third trimester if DNA >200,000 IU/mL
— FGM/C in pregnancy: plan defibulation before labor or in second stage; document type; avoid re-infibulation (federal/state laws prohibit)
— Mental health screen each trimester
— Plot growth on CDC charts; refer stunting/wasting to nutrition
— Lead level all <16; CDC reference 3.5 µg/dL — environmental investigation and repeat
— Developmental screening with ASQ-3 or PEDS in native language
— Anemia screen at 6–12 months and as indicated
— Dental referral by age 1
— School enrollment — federal law (Plyler v. Doe) entitles all children to public education regardless of immigration status
— Adolescents: confidential sexual health, contraception, HPV, depression screening; assess for trafficking and child marriage
— Often released to sponsors via ORR; high mental health needs
— Screen for prior detention, abuse, trafficking; mandated reporter obligations apply
Step 3 management: For an HBsAg-positive pregnant refugee, order HBV DNA, HBeAg, ALT in second trimester; if HBV DNA >200,000 IU/mL, start tenofovir at 28 weeks to reduce vertical transmission, in addition to standard infant HBIG + vaccine at birth.
Board pearl: All immigrant children are entitled to public school enrollment and emergency medical care regardless of documentation — Plyler v. Doe and EMTALA.
— Disseminated strongyloidiasis / hyperinfection syndrome: triggered by steroids, HTLV-1 co-infection, transplant — gram-negative bacteremia/meningitis from gut translocation; mortality >80%
— Reactivation TB in untreated LTBI — 5–10% lifetime risk, higher with HIV, diabetes, TNF inhibitors
— HBV reactivation with chemotherapy, rituximab — screen and prophylax with entecavir/TDF
— Chagas cardiomyopathy: dilated CM, apical aneurysm, arrhythmias, sudden cardiac death; megaesophagus, megacolon
— Schistosomiasis sequelae: bladder squamous cell carcinoma (S. haematobium), portal hypertension (S. mansoni/japonicum)
— Cysticercosis (neurocysticercosis): new-onset seizures in adults from Latin America — leading cause globally
— PTSD prevalence 10–40% in refugees; comorbid depression common
— Somatization, chronic pain
— Suicide risk elevated in first years post-resettlement and after asylum denial
— Substance use as self-medication
— Family violence — acculturation stress, role changes
— Late presentation of T2DM with complications (retinopathy, nephropathy)
— Untreated rheumatic heart disease → atrial fibrillation, heart failure, stroke
— Hemoglobinopathy crises and chronic anemia sequelae
— Medication errors from language barriers — wrong dose, wrong frequency
— Missed appointments mislabeled as "noncompliance" when actually transportation/childcare/work conflict
— Lost to follow-up across health system fragmentation
Board pearl: New-onset seizures in an adult immigrant from Latin America = neurocysticercosis until proven otherwise — order MRI brain, serology, and treat per stage (often albendazole + dexamethasone + antiepileptic, avoiding treatment of calcified-only lesions).
Step 3 management: Before any patient from an endemic region starts infliximab, rituximab, high-dose steroids, or chemotherapy, screen and treat for LTBI, HBV, and strongyloides — failure is the classic preventable-death vignette.
— Active pulmonary TB requiring isolation (airborne precautions, negative-pressure room)
— Severe malaria (parasitemia >5%, end-organ dysfunction, altered mental status) — IV artesunate
— Acute Chagas with myocarditis, decompensated cardiomyopathy
— Suicidal ideation with plan or recent attempt — psychiatric admission
— Disseminated strongyloidiasis suspected — ICU, ivermectin (consider subcutaneous via IND), broad antibiotics
— Acute hepatitis with coagulopathy, encephalopathy → liver transplant center
— Severe malnutrition in child (kwashiorkor, marasmus) — refeeding protocol with electrolyte monitoring
— Infectious disease: any complicated parasitic disease, MDR-TB, Chagas treatment, HIV management
— Hepatology: chronic HBV/HCV with cirrhosis, HCC surveillance, transplant eval
— Cardiology: rheumatic heart disease, Chagas cardiomyopathy, suspected arrhythmia
— OB/GYN: FGM/C defibulation, pregnancy with HBV, complex reproductive concerns
— Behavioral health/psychiatry: PTSD, torture survivors — refer to specialized survivor programs (e.g., HealthRight, Center for Victims of Torture)
— Neurology: neurocysticercosis, untreated epilepsy
— Genetics/hematology: hemoglobinopathies, thalassemia
— Dental: essentially universal referral
— Social work and legal aid: asylum medical-legal documentation, public benefits, housing
— TB (active and LTBI in some states), HIV, syphilis, hepatitis A/B/C, malaria, measles, pertussis, lead elevation — varies by state
— Coordinate with local refugee health coordinator and state health department
CCS pearl: When TB is confirmed active, order airborne isolation, ID consult, public health reporting, contact tracing, baseline LFTs/HIV/HBV/HCV, vision baseline (ethambutol), RIPE therapy as parallel orders — and counsel patient about DOT.
Board pearl: Provide an asylum medical affidavit only after appropriate training (PHR Asylum Network); flawed affidavits can harm a case.
— Strongyloides — universal screening; persists for decades
— Schistosomiasis — sub-Saharan, hematuria or GI
— Hookworm — iron deficiency anemia, ground itch
— Ascaris — biliary obstruction, pulmonary Loeffler
— Filariasis (lymphatic/Loa loa/onchocerca) — geographic
— Toxocara — visceral/ocular larva migrans
— Trichuris — rectal prolapse in children
— Allergic, drug, hypereosinophilic syndromes — non-infectious mimics
— Malaria — always rule out first in sub-Saharan African arrivals
— Typhoid (Salmonella Typhi) — relative bradycardia, rose spots
— Dengue — thrombocytopenia, retro-orbital pain, recent SE Asia/Latin America
— Visceral leishmaniasis (kala-azar) — fever, splenomegaly, pancytopenia
— Brucellosis — undulant fever, unpasteurized dairy
— Tuberculosis — subacute fever, weight loss, night sweats
— HIV seroconversion
— Hepatitis A/E — acute hepatitis
— Giardia, amebiasis (Entamoeba histolytica with liver abscess), cryptosporidium
— Cyclospora, cystoisospora in HIV
— Bacterial: Shigella, Salmonella, Campylobacter, ETEC
— Tropical sprue (post-infectious malabsorption)
— Acute HBV vs chronic vs resolved (interpret HBsAg, anti-HBc IgM/total, anti-HBs)
— HCV antibody can be false positive — confirm with RNA
— Hepatitis D superinfection in HBV — order anti-HDV
— Hepatitis E — pregnancy fulminant risk
Key distinction: Schistosoma haematobium = hematuria + bladder pathology; S. mansoni/japonicum = hepatosplenic/portal hypertension + GI. Both treated with praziquantel but surveillance differs.
Board pearl: Amebic liver abscess classically presents as a solitary right-lobe abscess in a young man from endemic region; serology + treat with metronidazole then paromomycin (luminal agent).
— Iron deficiency from diet, menstruation, hookworm
— Thalassemia (alpha/beta) — Mediterranean, Middle Eastern, Southeast Asian
— Sickle cell disease/trait — African, Middle Eastern
— G6PD deficiency — hemolysis triggers (fava beans, primaquine, dapsone, sulfa)
— B12/folate deficiency — dietary, especially elderly, vegetarians
— Anemia of chronic disease — TB, HIV, chronic HBV
— Lead toxicity — basophilic stippling
— Post-infectious bronchiectasis (childhood pneumonias)
— Biomass fuel COPD (cooking smoke exposure)
— Asthma (often undiagnosed)
— Paragonimiasis (lung fluke) — hemoptysis, eosinophilia, Asia/Africa/Latin America
— Pulmonary hydatid disease (Echinococcus)
— Neurocysticercosis (Latin America most common globally)
— CNS tuberculoma
— Toxoplasmosis (HIV)
— Cerebral malaria
— Untreated structural epilepsy from childhood
— PTSD-related somatization (headache, "all-over pain," GI distress)
— Depression with somatic predominance — culturally normative presentation
— Vitamin D deficiency causing diffuse pain
— Untreated chronic disease (hypothyroidism, diabetes neuropathy)
— Rheumatic heart disease vs congenital vs Chagas cardiomyopathy vs ischemic
— Apical aneurysm with preserved overall EF — classic Chagas
— Mitral stenosis in young adult — rheumatic until proven otherwise
— FGM/C complications: dyspareunia, recurrent UTI, dysmenorrhea, obstructed labor history
— Chronic PID from untreated STI
— Pelvic schistosomiasis (FGS — female genital schistosomiasis)
Key distinction: Treat somatic complaints as legitimate medical concerns AND screen for underlying depression/PTSD with validated translated tools — dismissing as "cultural" misses both diagnoses.
Board pearl: Female genital schistosomiasis can mimic cervical cancer or STI on exam — sandy patches, contact bleeding. Treat with praziquantel.
— After completing initial screening, transition refugee to standard primary care chronic disease management
— Diabetes: A1c every 3–6 months, ACE/ARB if albuminuria, statin per ASCVD risk
— Hypertension: goal <130/80 per ACC/AHA; lifestyle + first-line per JNC/ACC
— Hyperlipidemia: ASCVD risk calculator caveat — validated primarily in US populations; use clinical judgment
— HBV: lifelong monitoring with ALT, HBV DNA every 6–12 months; HCC surveillance
— HCV cured: still surveil if cirrhotic
— LTBI completed: counsel about future TB symptom recognition; no further testing usually needed
— Statin if 10-year ASCVD ≥7.5% (shared decision) or ≥20% (statin recommended)
— Aspirin per current USPSTF (individualized, not routine primary prevention >60)
— Smoking cessation, including khat, betel nut, hookah counseling
— Alcohol screening (AUDIT-C)
— Cancer screening on full US schedule
— Bone density screening women ≥65, earlier with risk factors (vitamin D deficiency common)
— Annual influenza, COVID per current schedule
— Td/Tdap every 10 years
— Pneumococcal age 65+ (PCV20 or PCV15+PPSV23)
— Zoster (RZV) ≥50
— Track immigration status changes (refugee → LPR at 1 year → citizen at 5 years)
— Connect with adjustment of status medical exam (Form I-693, civil surgeon required)
— Maintain insurance — Refugee Medical Assistance 12 months; transition to Medicaid/marketplace
— Discuss contraception options with cultural sensitivity
— Preconception folic acid, optimize chronic disease before pregnancy
— Address infertility, often stigmatized
Step 3 management: At the 1-year visit, complete the adjustment-of-status civil surgeon exam (Form I-693) if you're certified, documenting required vaccines and TB/syphilis/HBV screening — this is a tested longitudinal care milestone.
Board pearl: Refugee Medical Assistance covers only the first 12 months; plan insurance transition early to avoid coverage gaps in chronic disease care.
— Visit 1 (week 0–4): intake, screening labs, vaccines initiated, TB screen, mental health screen, social needs
— Visit 2 (week 2–4): lab review, presumptive parasite treatment, initiate LTBI if indicated, vaccine 2
— Visit 3 (week 6–8): complete vaccinations, dental/vision referrals, behavioral health follow-up
— Visit 4 (month 3): chronic disease management, repeat lead (children), titer checks
— Visit 5 (month 6): LTBI midpoint, HBV/HCV follow-up labs, parasite serology recheck
— Visit 6 (month 12): complete I-693 if applicable, transition to standard primary care cadence
— LTBI on INH/rifapentine: monthly clinical visits, LFTs if symptoms or baseline abnormal, vision check on ethambutol if active TB
— HBV antivirals: ALT, HBV DNA, creatinine, phosphate every 3–6 months
— HCV DAA: SVR12 (RNA 12 weeks after treatment end)
— Strongyloides post-treatment: serology titer at 6 and 12 months — should decline
— Chagas benznidazole: weekly CBC, LFTs first month; watch for rash, peripheral neuropathy
— Medication adherence and side effects
— Health system navigation: 911, urgent care vs ED, how to fill prescriptions
— Driving/seatbelts/car seats — high MVC mortality in newly arrived
— Smoke alarm, water temperature, lead-safe housing
— Nutrition transition (avoid ultra-processed Western diet pitfalls)
— Domestic violence resources, gender-based violence
— School engagement and parent-teacher communication
— Use teach-back to confirm understanding
— Ask about traditional healers; integrate respectfully
— Religious/dietary considerations (halal, kosher, fasting in Ramadan and medication timing — insulin, antibiotics)
CCS pearl: Order "interpreter," "counsel — medication adherence," and "schedule follow-up appointment" explicitly on CCS; transition-of-care orders score points.
Board pearl: During Ramadan, work with patient to adjust medication timing (e.g., long-acting insulin at iftar) rather than discouraging fasting — adherence and trust depend on shared decision-making.
— Title VI of the Civil Rights Act requires meaningful language access in federally funded healthcare (essentially all US health systems)
— Using family members (especially minors) as interpreters violates standards and HIPAA
— Document interpreter ID number in every encounter
— Literacy and educational background may be limited — use pictorial consent, teach-back, native-language forms
— Decisional capacity is not equivalent to English fluency or formal education
— Surrogate decision-making norms differ culturally (family-centered vs individual autonomy) — explore patient's preferred model
— Child abuse, elder abuse, intimate partner violence (state-specific)
— Trafficking — National Human Trafficking Hotline 1-888-373-7888; T-visa eligibility for victims
— FGM/C — federal law (18 USC 116) criminalizes performing it on minors in US; reporting obligations vary by state; do not report historical FGM/C performed abroad as abuse — focus on care
— Communicable disease reporting per state
— Physicians can provide affidavits supporting asylum claims (Istanbul Protocol framework)
— Requires training; document physical findings, psychological sequelae consistent with reported history
— Maintain professional objectivity; do not editorialize
— Use of emergency Medicaid, CHIP, WIC, vaccines, COVID services does NOT count toward public charge determinations
— Counsel patients to use medical care without fear; coordinate with legal aid for specifics
— Mental health, reproductive, and HIV diagnoses must remain confidential even from accompanying family
— Adolescent confidentiality follows state minor consent laws
— Refugees lost-to-follow-up commonly at end of Refugee Medical Assistance — proactive insurance transition counseling at month 9
— Medication reconciliation across providers and pharmacies (multiple languages on bottles helpful)
— Discharge instructions in patient's language with phone follow-up within 48–72 hours
Step 3 management: A 14-year-old refugee girl reveals during an interpreted visit that she fears being forced into marriage when returning to visit relatives. This triggers mandated reporting to child protective services, social work consult, and connection to legal aid for protective orders — child marriage is illegal in the US and constitutes child abuse.
Board pearl: Use of standard preventive medical services does NOT trigger public charge — reassure patients to access care.
Board pearl: When you see "newly arrived refugee" in a stem, the answer almost always involves either (1) screening you haven't done yet, (2) presumptive treatment, or (3) culturally informed management — rarely an exotic diagnosis without screening logic.
— "Newly arrived refugee from Ethiopia, asymptomatic, CBC shows WBC 8.2 with 12% eosinophils." → Strongyloides serology + presumptive ivermectin; do NOT start steroids for anything until treated
— "55-year-old man from Brazil being started on infliximab for Crohn's." → Screen LTBI (IGRA), HBV (HBsAg, anti-HBc, anti-HBs), strongyloides, Chagas
— "27-year-old refugee from Syria, no records." → Order serology for MMR/varicella/HBV, give Tdap, start HBV/HPV series, defer live vaccines if pregnancy possible until test negative
— Answer: HBV DNA, ALT, HBeAg; if DNA >200,000, tenofovir at 28 weeks; infant gets HBIG + HBV vaccine within 12 hours
— Adult from Mexico, focal seizure → MRI shows ring-enhancing lesions with scolex → neurocysticercosis, treat with albendazole + dexamethasone + antiepileptic (only viable cysts)
— "10-year-old translates for mother." → Use professional interpreter; family use is inappropriate
— Refugee with hypervigilance, intrusive memories, scars consistent with reported torture → RHS-15 or PTSD screen, refer to torture survivor program, trauma-informed exam
— Refugee from Cameroon with positive strongyloides serology → screen Loa loa microfilaria before ivermectin (fatal encephalopathy)
— P. vivax patient about to receive primaquine → check G6PD first
— Positive IGRA, normal CXR, asymptomatic → LTBI, treat with 3HP
— Refugee from sub-Saharan Africa, microscopic hematuria → schistosomiasis (S. haematobium), treat with praziquantel
— Mother declines WIC fearing immigration consequences → counsel that WIC/vaccines/Medicaid for children do not affect public charge
Step 3 management: When stem mentions immunosuppression in any foreign-born adult, the answer always includes screening for LTBI, HBV, and strongyloides before initiation.
Refugee and immigrant health screening is a structured, time-bounded primary care responsibility — a CDC-guided domestic health assessment within 30–90 days of arrival that integrates region-specific infectious disease screening, presumptive parasite treatment, vaccine catch-up, chronic disease and mental health screening, and trauma-informed cultural care, all delivered through certified medical interpreters and longitudinal follow-up.
Rapid recap bullets:
Board pearl: The single most testable concept is "screen before immunosuppress" — LTBI + HBV + strongyloides — because failure causes preventable death and is the archetypal Step 3 patient-safety vignette.