A patient fell from a ladder landing on the left side of the trunk with immediate onset of pain over the left lower ribs. The following day, the patient reports mild light-headedness along with severe pain over the left shoulder and left upper abdomen that increases with inhalation. Shoulder movement is mildly limited with reports of rib pain at end range. Which of the following conditions is MOST likely?

A patient fell from a ladder landing on the left side of the trunk with immediate onset of pain over the left lower ribs. The following day, the patient reports mild light-headedness along with severe pain over the left shoulder and left upper abdomen that increases with inhalation. Shoulder movement is mildly limited with reports of rib pain at end range. Which of the following conditions is MOST likely?

• A. Shoulder fracture
• B. Ruptured spleen
• C. Acute cholecystitis
• D. Pulmonary embolism

Answer: (D)

Trauma to the left upper quadrant can irritate the diaphragm and cause referred pain to the left shoulder via the phrenic nerve (Kehr sign). When a fall is followed by severe left shoulder pain that worsens with inhalation and concurrent left upper abdominal pain, splenic injury, including rupture, becomes the most likely diagnosis. The mild light-headedness the next day supports possible internal bleeding. This pattern fits splenic injury much more than the other options. A shoulder fracture would produce localized shoulder pain with limited movement and not typically accompany left upper abdominal symptoms after a fall. Acute cholecystitis presents with right upper quadrant pain and fever, not a trauma-driven left-sided presentation. Pulmonary embolism would cause chest pain and dyspnea rather than this combination of diaphragmatic irritation and abdominal symptomatology following trauma.

Trauma to the left upper quadrant can irritate the diaphragm and cause referred pain to the left shoulder via the phrenic nerve (Kehr sign). When a fall is followed by severe left shoulder pain that worsens with inhalation and concurrent left upper abdominal pain, splenic injury, including rupture, becomes the most likely diagnosis. The mild light-headedness the next day supports possible internal bleeding.

This pattern fits splenic injury much more than the other options. A shoulder fracture would produce localized shoulder pain with limited movement and not typically accompany left upper abdominal symptoms after a fall. Acute cholecystitis presents with right upper quadrant pain and fever, not a trauma-driven left-sided presentation. Pulmonary embolism would cause chest pain and dyspnea rather than this combination of diaphragmatic irritation and abdominal symptomatology following trauma.