Adam III: Third Time Lucky?

Blood & Lymphoreticular System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S28_F1.jpg"}},{"insert":"\n\n"},{"insert":"Sometime ago, you treated 15-year-old high-schooler and rugby team captain Adam McGlynn for infectious mononucleosis. You cleared him to attend school, but asked that he avoid contact sports for four weeks.\n\nUnfortunately, Adam didn\u0027t heed your advice, and developed a splenic rupture while playing rugby. You managed him conservatively and discharged him home after a couple of days in hospital.\n\nThe story continues now ...\n"}]}


{"ops":[{"insert":"Around 6 weeks after discharge, Adam is brought to the ER once more. He is accompanied by his mother (and experienced family physician) Dr. McGlynn.\n\nAdam has had abdominal pain since waking up today. He also has had fever since yesterday morning, and a cough for the last three days.\n\nYou find out that the abdominal pain is localized to the left upper quadrant, and that it is 5\/10 on the pain scale. You also recall that Adam has no chronic illnesses, is not on any medications, is fully immunized, has no allergies, and doesn\u2019t drink alcohol, smoke or take drugs.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S28_F3.jpg"}},{"insert":"\n\n"},{"insert":"Adam\u2019s temperature is 102.02\u00b0F (38.9\u00b0C). The other vitals are stable.\n\nRespiratory examination reveals dullness to percussion and coarse crackles over the left lung base. Examination of the abdomen is significant for tenderness over the left upper quadrant, without guarding or rigidity and a positive Castell sign.\n\nBaseline laboratory studies are only significant for a neutrophil leukocytosis with left shift. Chest x-rays show an elevated left hemi-diaphragm and consolidation over the left lower zone. An ultrasound scan of the abdomen confirms splenomegaly; a 7 cm x 7 cm bilocular anechoic mass with air patterns is seen adjacent to the spleen.\n"}]}


{"ops":[{"insert":"What is your diagnosis?\n"}]}
1. Delayed splenic rupture
2. Splenic abscess