We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

Jennifer Hartwell, MD; Antonio Gangemi, MD; Steven Salzman, DO
[+] Author Affiliations

Author Affiliations: Advocate Christ Medical Center, Oak Lawn, Illinois; and University of Illinois at Chicago, Chicago, Illinois.


Arch Surg. 2011;146(7):881-882. doi:10.1001/archsurg.2011.162-a.
Text Size: A A A
Published online

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).

Place holder to copy figure label and caption
Graphic Jump Location

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


Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomography of the abdomen demonstrating splenic hematoma.




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections

The Rational Clinical Examination
Evidence Summary and Review 2

The Rational Clinical Examination EDUCATION GUIDES
Lumbar Puncture