A 27-year-old man seen on presentation with blunt trauma to the lower abdomen from heavy machinery trailer pinning him against a large truck for several seconds. Patient reported immediate onset of lower abdominal pain, right > left. Reports 10/10 pain in RLQ radiating to back. Denies any head trauma, LOC, chest pain, or dyspnea. Reports feeling lightheaded and nauseated. 5 episodes of emesis in 4 hours since the incident. Patient denies voiding since incident. PMH/PSH: Traumatic splenectomy 3 years prior.
Exam
Primary Trauma Survey Airway: Intact, talking Breathing: RR 14, SaO2 98 % Circulation: HR 82, BP 110/70 Disability: GCS 15, PERRL, MAE FAST equivocal due to inability to visualize ectopic right kidney and obtain hepatorenal recess Secondary Trauma Survey HEENT: no abrasions or facial hematoma. Neck: trachea midline, no JVD, no hematoma, no crepitus. No C-spine tenderness. Chest: non-tender, symmetric chest wall motion, CTAB, no crepitus, no midline L-spine or T-spine tenderness. Abdomen: distended, diffusely TTP, guarding, no signs of external trauma. Pelvis: stable, mild pain with stability check radiating to back, no flank hematoma, no hip pain bilaterally. 2cm right flank superficial abrasion. GU: no perineal hematoma, no blood at the urethral meatus. DRE with normal sphincter tone, no blood. Extremities: no external signs of injury. Full ROM and strength in bilateral UE and LE. Vascular: 2+ pulses throughout bilaterally, no edema. Neuro: 5/5 strength and sensation intact to light touch throughout all extremities. Key PE Findings
• Ectopic right kidney in pelvis prevented an adequate FAST exam
• Distended and diffusely tender abdomen with guarding Labs: CBC: 22>13.8/41.6<279 H/H compared to baseline 13.2/38.9 from chart review 139/3.8|107/20|11/1.17<121 AST 24, ALT 25, Alk Phos 81, Tbili 0.9 PT 14, INR 1.1, PTT25 UA: 2+ protein, 3+ blood, >182 RBC Lipase 10
Findings
• CT IVP: Injury to the renal pelvis is approximately located at the posterior right lateral margin. CT IVP demonstrated extension of laceration into collecting system.
• Subcapsular renal fluid with a laceration may represent blood and/or urine. Note: CT IVP initially was not performed because of noted extravasation on outside hospital imaging but he did have a 2nd CT IVP (5/30)-two days after admission with findings as above without evidence of active bleeding or leak from urinary collecting system.
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