Author: Peter Karagozian, III, MD
Co Author #1: K. Michele Kirk, MD
Senior Editor: Yaowen Hu, MD, MBA
Editor: Rehal Bhojani, MD

Patient Presentation:
The patient was a healthy 19 year old male college athlete, who plays wide receiver in football, presenting with left abdominal injury.

History:
He attempted to avoid a tackle with the opponent diving towards his knees. His elbow dug into his own ribs after landing abruptly on his left side during the second quarter of the game. He had mild to moderate rib tenderness but was able to finish the game. He had no respiratory distress or abdominal pain at primary assessment or during half time. The athlete noted that he has new-onset blood in his urine along with increasing left flank pain with 7/10 severity. He denied any worsening pain in his left ribs or respiratory difficulty. He had no remarkable past medical, family, or social history. He was not on anticoagulants or medications with urine discoloration effects. He denied any associated symptoms of nausea, vomiting, abdomino-pelvic pain, fevers, chills, hematemesis, or hemoptysis. He was promptly taken to local emergency department for further investigation and higher level of care.

Physical Exam:
Vitals: blood pressure 128/59 mm Hg, heart rate 77 bpm, respiratory rate 18 bpm, temperature 98.4 deg F, oxygen saturation 100% on room air.
General: no acute distress, alert and oriented, calm, cooperative.
HEENT: within normal limits.
Neck: within normal limits.
Cardiopulmonary: within normal limits.
Abdomen: soft, bowel sounds intact in all quadrants, no epigastric or suprapubic tenderness to palpation, no rebound or guarding, negative Murphy, negative Rovsing, negative psoas and obturator signs, positive left flank costovertebral angle tenderness to palpation and percussion.
Musculoskeletal: minimal inferior left rib tenderness to palpation.
Neurologic: within normal limits.
Dermatologic: no significant skin ecchymosis or abrasions noted.

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