What should a 22-year-old male do with recurrent upper respiratory infection (URI) symptoms, intermittent cough, headache, right quadrant tenderness to touch, guarding, and low-grade fever?

Immediate Evaluation for Acute Abdomen Required

This 22-year-old male requires urgent evaluation in the emergency department for possible acute appendicitis or other serious intra-abdominal pathology, as the combination of right quadrant tenderness with guarding and fever represents a surgical emergency that supersedes the URI symptoms. 1, 2

Critical Clinical Assessment

The presence of right quadrant tenderness with guarding is a red flag that demands immediate attention:

• Guarding has an odds ratio of 3.07 for acute appendicitis, making it a highly significant finding that cannot be dismissed 3
• Muscular rigidity and rebound tenderness are even stronger predictors (odds ratios of 5.03 and 3.34 respectively) and should be specifically assessed 3
• Right-sided tenderness with guarding, even with concurrent URI symptoms, requires exclusion of appendicitis, cholecystitis, hepatitis, or other serious abdominal pathology 2

Why URI Symptoms Are Secondary

While the recurrent URI symptoms, cough, and headache suggest a viral upper respiratory infection:

• Viral URIs typically resolve within 5-7 days and do not cause abdominal guarding 4
• The low-grade fever could be attributed to either URI or intra-abdominal infection, but fever with abdominal guarding mandates surgical evaluation 2
• Concurrent URI symptoms do not exclude serious abdominal pathology and may represent two separate processes 1, 4

Immediate Action Required

Transport to the emergency department immediately, ideally by EMS if symptoms are severe: 5

• Physical examination must assess for rebound tenderness, muscular rigidity, and the exact location and severity of right quadrant tenderness 3, 2
• Laboratory evaluation including complete blood count, comprehensive metabolic panel, and inflammatory markers 2
• Imaging studies (ultrasound or CT scan) are necessary to evaluate the right upper quadrant and rule out appendicitis, cholecystitis, or hepatobiliary pathology 2

Common Pitfall to Avoid

Do not attribute abdominal guarding to a viral URI or delay evaluation based on the presence of respiratory symptoms. 1, 4 The combination of guarding with fever represents potential peritoneal irritation, which is a surgical emergency regardless of concurrent upper respiratory symptoms. 3, 2

If Appendicitis or Cholecystitis Is Excluded

Only after serious intra-abdominal pathology has been ruled out should the URI symptoms be addressed:

• Antibiotics are not indicated for uncomplicated viral URIs and provide no benefit 1, 4
• Supportive care with hydration and symptomatic treatment is appropriate for viral URI 4
• Suspect bacterial sinusitis only if URI symptoms persist ≥10 days without improvement, worsen after initial improvement, or present with severe onset (high fever >39°C with purulent discharge for 3-4 consecutive days) 5, 4