A 14-year-old boy is brought to the emergency department by ambulance from his school. The patient is accompanied by his gym teacher, who says the boy suddenly developed left-sided abdominal pain during track practice. The patient has no significant medical history, and vaccinations are up to date. Temperature is 36.7 C (98 F), blood pressure is 65/30 mm Hg, pulse is 160/min, and respirations are 30/min. Oxygen saturation is 100% on room air. On examination, the patient is pale, diaphoretic, and in distress. Cardiopulmonary examination is normal. The abdomen is distended and diffusely tender to palpation. He has no skin rash. Bedside ultrasound examination reveals free fluid in the abdomen. Hemoglobin is 9 g/dL. Further evaluation of this patient would most likely reveal which of the following?

Question

A 14-year-old boy is brought to the emergency department by ambulance from his school.  The patient is accompanied by his gym teacher, who says the boy suddenly developed left-sided abdominal pain during track practice.  The patient has no significant medical history, and vaccinations are up to date.  Temperature is 36.7 C (98 F), blood pressure is 65/30 mm Hg, pulse is 160/min, and respirations are 30/min.  Oxygen saturation is 100% on room air.  On examination, the patient is pale, diaphoretic, and in distress.  Cardiopulmonary examination is normal.  The abdomen is distended and diffusely tender to palpation.  He has no skin rash.  Bedside ultrasound examination reveals free fluid in the abdomen.  Hemoglobin is 9 g/dL.  Further evaluation of this patient would most likely reveal which of the following?

Quizplus · Accepted Answer

11ec25c8_d5e6_277a_bc81_91456bab9ac6_MD0003_00 This patient with acute, left-sided abdominal pain has anemia, free fluid in the abdomen, and signs of shock. These findings are concerning for intraperitoneal hemorrhage due to a ruptured spleen, a potentially fatal condition. Splenic rupture is most commonly caused by high-force, blunt abdominal trauma (eg, motor vehicle collision) but can also occur spontaneously. The greatest risk factor for atraumatic splenic rupture is stretching of the splenic capsule due to infection or malignancy (eg, leukemia). Infectious mononucleosis, caused by Epstein-Barr virus, is associated with splenomegaly in up to 50% of cases, and splenic rupture within a month of symptom onset is a rare but serious complication. Additional history in this otherwise healthy patient likely includes recent symptoms of infectious mononucleosis, such as fever, pharyngitis, and lymphadenopathy. The severity of fever or pharyngitis does not correlate with risk of splenic rupture, which may be the presenting feature in a patient with mild symptoms. Because splenic rupture can occur even if the spleen is not initially palpable, activities that increase the risk of rupture (eg, contact sports) should be avoided for 3-4 weeks from the time of initial diagnosis. (Choice A) Sickle cell disease and its variants (eg, hemoglobin SC disease) are associated with splenic sequestration crisis. Symptoms include anemia, severe abdominal pain, and splenomegaly. However, anemia is due to pooled red blood cells in the spleen, not intraperitoneal hemorrhage as seen in this patient with abdominal free fluid. In addition, this diagnosis is unlikely in a previously healthy adolescent. (Choice B) Familial hypertriglyceridemia is an autosomal dominant condition associated with recurrent pancreatitis. Chronic pancreatitis can cause splenic complications but is unlikely in this patient with no history of pancreatitis. (Choice C) Splenic congestion and splenomegaly due to cirrhosis can increase the risk of splenic rupture but are unlikely in a healthy patient with no signs of liver disease (eg, jaundice). (Choice D) A perforated peptic ulcer (PUD) can also present with abdominal pain and rigidity, but ultrasound examination typically reveals free intraperitoneal air, not just fluid. Left upper quadrant pain (than epigastric) is also more likely with splenic pathology. (Choice E) Drug-induced immune hemolytic anemia following antibiotic use presents with jaundice, dark urine, abdominal pain, and anemia. Spleen enlargement can occur, but rupture is rare. Educational objective: Splenic rupture presents with acute abdominal pain, anemia, and shock due to intraperitoneal hemorrhage. Atraumatic rupture is a rare, potentially fatal complication of infectious mononucleosis, a viral infection associated with splenomegaly. References: Atraumatic splenic rupture secondary to Epstein-Barr virus infection. (http://www.ncbi.nlm.nih.gov/pubmed/28119438) Epstein-Barr virus and its association with disease - a review of relevance to general practice. (http://www.ncbi.nlm.nih.gov/pubmed/31088382)

A 14-Year-Old Boy Is Brought to the Emergency Department by Ambulance