SECTION EDITOR: CARL E. BREDENBERG, MD
Author Affiliations: Advocate Christ Medical Center, Oak Lawn, Illinois; and University of Illinois at Chicago, Chicago, Illinois.
A 51-year-old man presented to the emergency department after experiencing a near syncopal episode and diaphoresis while riding the train home from work. He was seen by his primary care physician in an outpatient setting and was found to be orthostatic and sent immediately to the emergency department. On arrival at the emergency department, he was found to have a blood pressure of 92/62 mm Hg and heart rate of 112 beats per minute. His respiratory rate was 16 breaths per minute; pulse oximetry, 100% with room air; and temperature, 97.9°F. He was immediately given 2 liters of crystalloid intravenous fluids, and repeated blood pressure was 110/78 mm Hg. He had abdominal pain, primarily in the left upper quadrant, and felt light-headed and fatigued. He described that the pain had started the night before. He specifically denied chest pain, shortness of breath, cough, fevers, weight loss, diarrhea, or any other recent illness. He was otherwise in good health and reported no current medications or previous surgeries. He denied smoking, alcohol, or illicit drug use. He had no allergies. He did note a recent injury about 3 months prior in which he was involved in a sledding accident and was admitted to our institution for a grade 3 splenic injury noted on a computed tomographic (CT) scan. He successfully completed a period of observation with stable findings on physical examination and hemodynamic stability throughout his hospital course and was discharged home after 2 days without requiring surgery for the injury. At the current visit, physical examination revealed a calm and cooperative gentleman. His lungs were clear bilaterally and heart examination revealed tachycardia with regular rhythm. His abdomen was soft, not distended, and had mild pain on palpation of the left upper quadrant but no evidence of peritonitis. His extremities were warm, without edema, and he had palpable pulses in all 4 extremities.
Laboratory values were as follows: white blood cell count, 19.5 × 103/μL; hemoglobin level, 12.9 g/dL (to convert to grams per liter, multiply by 10.0); hematocrit, 38.5; platelet count, 203; and international normalized ratio, 1.1. After initial resuscitation in the emergency department, a chest x-ray was obtained, identifying a small left pleural effusion, but was otherwise negative. A CT scan of the chest, abdomen, and pelvis was completed (Figure 1).
Figure 1. Computed tomography of the abdomen demonstrating splenic hematoma.
A. Late-onset traumatic chylothorax
B. Splenic rupture
C. Left-sided pneumonia with reactive pleural effusion
D. Splenic infarction
Hartwell J, Gangemi A, Salzman S. Image of the Month—Quiz Case. Arch Surg. 2011;146(7):881-882. doi:10.1001/archsurg.2011.162-a