the modern spleen

[caesar ursic]

Actual current case of mine:

15 yo male 'accidentally' tackled during spring football training (it was
supposed to be a 'no-contact' practice session, but...oh well.. )  He said
the blow 'knocked the wind out of me and hurt pretty bad."  He went home
that afternoon feeling a bit 'weak' and tried to eat but could not.  Slept
poorly due to pain in left upper abdomen/lower chest.  Next morning in more
pain, so mom takes him to our ER.  He tells me his left upped belly hurts.
He's not hungry even though he skipped dinner and breakfast.

 His vital signs on arrival:  BP 136/81   HR: 90   RR: 16   TEMP: 36.5

Exam: He looks pretty good, albeit worried.
Skin: warm, well perfused,  No scleral icterus
Lungs: Equal breath sounds.
Chest: minimal tenderness over left lower anterior ribs
Heart: Normal heart tones.
Abdomen:  non-distended, no bruises,  bowel sounds present and normal.
Tender in LUQ with some voluntary guarding; other areas of abdomen are
NON-tender and soft.
Back and spine are normal.
Genitourinary exam: normal
Rectal exam: normal

Hb: 13.9 g/dL (prior to any intravenous fluids).  WBC 17,000.  Serum amylase
and lipase are normal.  T. Bili: 2.1.  ALT and AST: normal

urinalysis: grossly clear (i.e. no gross hematuria), microscopy shows 5-10
RBCs per high-power-field.

CT scan of abdomen:  selected cuts
here<http://trauma.homestead.com/spleen_ct.html>(
http://trauma.homestead.com/spleen_ct.html). Remainder of abdominal CT shows
NO pneumoperitoneum, NO liver/kidney/pancreatic injury, NO oral contrast
extravasation, NO periduodenal fluid or thickened loops of intestine.  there
is some fluid in the pelvis and around the lower liver.

Remember, this injury is now approx 18 hours old.  His BP on repeated
determinations remains normal, and he is NOT tachycardic.

How would you manage this patient?  Next step(s)??

C. Ursic, MD
Santa Fe
USA