How should I evaluate and manage a 23-year-old woman presenting with sore throat and abdominal pain?

Evaluation of a 23-Year-Old Woman with Sore Throat and Abdominal Pain

Initial Assessment

Begin by assessing vital signs to detect fever, tachycardia, or hypotension, which may indicate infection or serious complications requiring urgent intervention. 1

Sore Throat Evaluation

• Assess for group A streptococcal pharyngitis using clinical features: fever, tonsillopharyngeal exudates, tender anterior cervical lymphadenopathy, and absence of cough or coryza 2, 3
• Headache, nausea, vomiting, and abdominal pain commonly occur with streptococcal pharyngitis, especially in children and young adults 2
• Apply the Centor criteria or McIsaac score to determine need for testing: fever >100.4°F, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough 3, 4
• Perform rapid streptococcal antigen testing if 3-4 Centor criteria are present; if negative, follow with throat culture 2, 3
• Consider infectious mononucleosis if generalized lymphadenopathy or splenomegaly is present 2

Abdominal Pain Evaluation

Determine the location, onset, and character of abdominal pain to guide your differential diagnosis and imaging strategy. 1

Critical Red Flags to Exclude Immediately

• Tachycardia is the most sensitive early warning sign of surgical complications and should trigger urgent investigation 1, 5
• Peritoneal signs (rigid abdomen, rebound tenderness) indicate perforation or ischemia requiring urgent surgical evaluation 1, 6
• Pain out of proportion to physical findings strongly suggests mesenteric ischemia 1, 5
• Hemodynamic instability suggests bleeding or sepsis 1, 6

Essential History Elements

• Document pain location: epigastric pain with sore throat may suggest referred pain from pharyngitis, but requires evaluation for peptic ulcer disease, gastritis, or pancreatitis 6
• Ask about last bowel movement and passage of gas (85% sensitivity for bowel obstruction in patients with prior surgery) 1
• Assess for nausea, vomiting, diarrhea, and fever 1
• In all women of reproductive age, consider ectopic pregnancy, ovarian torsion, and pelvic inflammatory disease 1, 6

Laboratory Testing

Obtain mandatory β-hCG testing before any imaging in all women of reproductive age 1, 5

• Complete blood count to evaluate for leukocytosis suggesting infection or inflammation 1, 5
• C-reactive protein has superior sensitivity and specificity compared to white blood cell count for ruling in surgical disease 1, 5
• Consider metabolic panel, liver function tests, amylase, and lipase if epigastric pain is present 1
• Throat culture or rapid streptococcal antigen testing based on Centor criteria 2, 3

Imaging Strategy

For nonlocalized or diffuse abdominal pain with fever, CT abdomen and pelvis with IV contrast is the optimal initial imaging choice 5

• For epigastric pain: consider upper GI evaluation if gastritis or peptic ulcer disease is suspected 1
• For right lower quadrant pain: abdominal ultrasound is the most appropriate initial imaging 1, 5
• For pelvic pain: CT abdomen and pelvis with contrast 1, 5
• Avoid routine plain radiographs as they have limited diagnostic value 1, 5

Differential Diagnosis

Combined Presentation Considerations

• Streptococcal pharyngitis commonly causes abdominal pain, nausea, and vomiting, particularly in young adults 2
• Infectious mononucleosis can present with pharyngitis, generalized lymphadenopathy, and abdominal pain from splenomegaly 2
• Acute viral pharyngitis may be accompanied by gastrointestinal symptoms including diarrhea 2

Abdominal-Specific Differentials

• Appendicitis (most critical to exclude in right lower quadrant pain) 6
• Gastritis or peptic ulcer disease (epigastric pain) 6
• Pelvic inflammatory disease or ovarian pathology in women of reproductive age 1, 6
• Acute pancreatitis (epigastric pain radiating to back) 6

Common Pitfalls to Avoid

• Do not dismiss abdominal pain as simply related to pharyngitis without proper evaluation—serious surgical conditions can coexist 1, 6
• Failing to obtain β-hCG testing before imaging can delay diagnosis of ectopic pregnancy 6, 5
• Over-relying on normal laboratory values early in disease can lead to missed diagnoses 1
• Normal physical examination does not exclude serious pathology, particularly in early presentations 1, 5

Treatment Approach

• If streptococcal pharyngitis is confirmed, treat with penicillin (10 days oral) or amoxicillin 3
• Provide oral analgesics and topical anesthetics for symptom management 4
• If abdominal imaging reveals surgical pathology, consult acute care surgery immediately 2
• Ensure adequate hydration and electrolyte correction 2