What are the best next steps for a female patient with possible fever, vomiting, diarrhea, and abdominal pain, whose symptoms may be related to ovulation or hormonal changes?

Immediate Assessment and Management

Given the constellation of vomiting, diarrhea, and abdominal pain in a female patient with possible fever, you must immediately assess for COVID-19 and other viral gastroenteritis, obtain vital signs including temperature measurement, and evaluate hydration status and severity of symptoms to determine if outpatient management is safe or if hospital admission is required. 1

Priority: Obtain Temperature Measurement

• You must measure her temperature - this is not optional, as fever presence fundamentally changes risk stratification and management 1
• Fever (≥38.3°C/101°F) combined with GI symptoms increases COVID-19 risk by 70% (adjusted OR 1.7) 1
• Without temperature data, you cannot properly risk-stratify this patient 2

Immediate Clinical Assessment

Key History Elements to Obtain Now

• COVID-19 exposure history: High-risk contacts, recent travel, or exposure during high-prevalence periods 3
• Symptom timeline: GI symptoms can precede respiratory symptoms by several days in COVID-19 3, 1
• Associated symptoms: Specifically ask about cough, shortness of breath, chills, muscle pain, headache, sore throat, loss of taste/smell 3
• Hydration status: Ability to tolerate oral intake, urine output, dizziness when standing 1
• Duration and severity: Onset timing, frequency of vomiting/diarrhea, presence of blood 3

Physical Examination Priorities

• Vital signs including orthostatic measurements to assess dehydration 1
• Abdominal examination for peritoneal signs or localized tenderness 4
• Hydration status: mucous membranes, skin turgor, capillary refill 1
• Respiratory examination even if no respiratory complaints 1, 4

Diagnostic Testing Required

COVID-19 Testing is Mandatory

• Nasopharyngeal RT-PCR for SARS-CoV-2 should be performed immediately given the combination of GI symptoms (vomiting, diarrhea, abdominal pain) 1
• This testing is indicated even if respiratory symptoms are absent, as 2.9-6.8% of COVID-19 patients present with abdominal pain and GI symptoms may be the only initial manifestation 4
• Testing is particularly important during high-prevalence periods 3

Additional Laboratory Studies

• Comprehensive metabolic panel including liver enzymes (AST/ALT elevated in 15-56% of COVID-19 cases with GI symptoms) 1
• Electrolytes to assess for dehydration and guide replacement 1
• Stool testing for bacterial pathogens and C. difficile to exclude bacterial causes 1

Management Algorithm Based on Severity

Outpatient Management (If All Criteria Met)

Patient can be managed at home ONLY if:

• Able to tolerate oral fluids 1
• No signs of severe dehydration 1
• No respiratory distress 1
• No abnormal vital signs or concerning physical findings 1
• Reliable for follow-up 1

Outpatient treatment includes:

• Aggressive oral hydration with electrolyte solutions 1
• Anti-emetics (ondansetron or metoclopramide) with mandatory QTc monitoring if using multiple medications 1
• Loperamide for diarrhea management after bacterial pathogens excluded 1
• Daily monitoring for development of respiratory symptoms or clinical deterioration 3

Hospital Admission Required If Any of These Present

• Inability to tolerate oral intake 1
• Significant dehydration or orthostatic vital sign changes 1
• Respiratory distress or hypoxia 1
• Abnormal liver enzymes (associated with severe COVID-19) 1, 4
• Elderly patient with any concerning features 1
• Immunocompromised status 1

Critical Pitfall to Avoid

Do not dismiss this as simple "ovulation pain" or hormonal changes without excluding infectious causes. 4 The combination of vomiting, diarrhea, and abdominal pain represents a potentially serious infectious process, particularly COVID-19, which can present with GI symptoms preceding respiratory manifestations by days 3, 1. Failure to consider COVID-19 in patients with abdominal pain and GI symptoms can delay appropriate isolation measures and increase transmission risk 4.

Monitoring Parameters if Managed as Outpatient

• Daily assessment for development of respiratory symptoms (cough, shortness of breath) 3
• Hydration status and ability to maintain oral intake 1
• Worsening abdominal pain or development of peritoneal signs 4
• QTc monitoring if using anti-emetics, particularly if multiple QT-prolonging medications 1
• Temperature monitoring (which you must begin doing immediately) 1

Regarding Hormonal/Ovulation Explanation

While mid-cycle ovulation can cause mild abdominal discomfort, it does not cause vomiting, diarrhea, or fever. The presence of these systemic GI symptoms makes an infectious etiology far more likely and requires the workup outlined above before attributing symptoms to hormonal changes.