Step-by-Step Evaluation for 26F with Fever, Stomach Upset, and Neck Pain in PCP Office
A thorough evaluation should begin with targeted history and physical examination focusing on infectious causes, particularly tickborne illnesses, meningitis, and urinary tract infections, followed by appropriate laboratory testing and imaging as indicated by initial findings.
Initial Assessment
History - Key Elements to Obtain:
- Duration and pattern of fever (continuous vs intermittent)
- Character of neck pain (stiff vs muscular)
- Nature of stomach upset (nausea, vomiting, diarrhea)
- Recent tick exposure or outdoor activities
- Travel history
- Contact with ill persons
- Urinary symptoms (dysuria, frequency, urgency)
- Headache characteristics
- Rash presence or absence
- Neurological symptoms (altered mental status, photophobia)
Physical Examination - Critical Components:
- Vital signs (temperature, heart rate, blood pressure, respiratory rate)
- Neck examination for stiffness, range of motion, and tenderness
- Neurological examination (mental status, cranial nerves, focal deficits)
- Skin examination for rashes (particularly petechial or maculopapular)
- Abdominal examination
- Lymph node examination
Laboratory Testing
First-line Tests:
- Complete blood count (CBC) with differential 1, 2
- Basic metabolic panel 2
- Urinalysis and urine culture 2
- C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR) 1, 2
- Blood cultures (if temperature ≥38.3°C or signs of systemic inflammatory response) 2
Second-line Tests (Based on Initial Findings):
- PCR for tickborne illnesses if suspicion exists (E. chaffeensis, A. phagocytophilum) 1
- Serologic testing for tickborne diseases if indicated 1
- Liver function tests if abdominal symptoms are prominent 2
Imaging
- Consider CT abdomen/pelvis with IV contrast if abdominal symptoms are severe or focal 1
- Consider chest X-ray if respiratory symptoms are present 2
Special Considerations
Meningitis Evaluation:
If neck stiffness is present with fever, especially with headache or altered mental status:
- Immediate referral to emergency department is warranted 1
- Do not rely on Kernig's or Brudzinski's signs (poor sensitivity) 1
- Lumbar puncture would be performed in the ED setting, not PCP office
Tickborne Illness Evaluation:
- Pay careful attention to leukopenia and thrombocytopenia, which are characteristic of ehrlichiosis and other tickborne illnesses 1
- Note that rash may be absent in many tickborne illnesses, particularly in adults with ehrlichiosis 1
Vertebral Osteomyelitis Consideration:
- If neck pain is severe, localized, and associated with elevated ESR/CRP, consider native vertebral osteomyelitis 1
- MRI would be indicated if this diagnosis is suspected 1
Management Algorithm
If signs of meningitis or severe sepsis are present:
If stable with fever and nonspecific symptoms:
- Complete first-line laboratory testing
- Consider empiric treatment based on most likely diagnosis while awaiting results
If tickborne illness is suspected:
- Consider empiric doxycycline while awaiting test results 1
- Arrange close follow-up within 24-48 hours
If abdominal symptoms predominate:
- Focus evaluation on gastrointestinal and genitourinary causes
- Consider imaging if symptoms are severe or focal 1
Common Pitfalls to Avoid
- Failing to consider tickborne illnesses in patients with fever and nonspecific symptoms 1
- Relying on presence of rash to diagnose or exclude tickborne diseases 1
- Missing meningitis due to incomplete neurological examination 1
- Delaying transfer to emergency department when concerning features are present 1
- Overlooking non-infectious causes of fever and pain 2
By following this structured approach, the primary care physician can efficiently evaluate this young female patient with fever, stomach upset, and neck pain, ensuring that potentially serious conditions are not missed.