What is the best course of action for a 15-year-old male with a history of multiple abdominal issues, presenting with mild left upper abdominal pain after blunt trauma, who has no current signs of hematoma, redness, or swelling, but has a history of dizziness, nausea, and vomiting that have since resolved?

Management of Mild Left Upper Abdominal Pain After Blunt Trauma in a Hemodynamically Stable Adolescent

This patient can be safely discharged home with reassurance and return precautions, as he is hemodynamically stable with minimal symptoms, no peritoneal signs, and resolution of his concerning symptoms from two days ago. 1

Clinical Assessment

This 15-year-old presents with:

• Minimal pain (2/10) only with deep breathing and palpation
• No hematoma, redness, or swelling on current examination
• Resolution of previously concerning symptoms (dizziness, nausea, vomiting from prior visit)
• Hemodynamic stability (implied by ability to present for outpatient evaluation)
• No peritoneal signs (no rebound tenderness, rigidity, or guarding mentioned)
• No ongoing gastrointestinal symptoms (no nausea, vomiting, or diarrhea)

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Why Imaging is Not Indicated

In clinically stable patients with isolated blunt abdominal trauma who lack peritoneal signs or hemodynamic instability, CT imaging is not required when symptoms are minimal and improving. 1 The key decision point is whether there is clinical suspicion for significant intra-abdominal injury requiring intervention. 1

This patient does not meet criteria for imaging because:

• Pain is mild (2/10) and localized to the superficial trauma site 1
• No signs of ongoing bleeding (no hematoma, no hemodynamic changes) 1
• No peritoneal irritation (which would suggest hollow viscus injury or ongoing bleeding) 1
• Symptoms are improving rather than progressing over the 48-hour period 1

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Disposition and Safety Net

Clinically stable patients with isolated blunt abdominal trauma and reassuring clinical examination can be safely discharged. 1 However, specific return precautions must be provided:

Return immediately if:

• Worsening abdominal pain or development of severe pain 1
• Dizziness, lightheadedness, or syncope (suggesting delayed bleeding) 1
• Nausea, vomiting, or inability to tolerate oral intake 1
• Abdominal distension or rigidity (suggesting peritonitis or bleeding) 1
• Fever (suggesting infection or delayed perforation) 1
• Shoulder pain (suggesting diaphragmatic irritation from blood or free air) 1

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Critical Pitfalls to Avoid

Do not attribute all symptoms to superficial trauma without considering delayed presentation of solid organ or hollow viscus injury. 2 However, in this case, the 48-hour time window with symptom improvement rather than progression makes significant occult injury extremely unlikely. 1

Do not miss delayed bowel perforation, which typically presents with progressive symptoms over 24-48 hours including worsening pain, fever, and peritoneal signs—none of which this patient exhibits. 1

The patient's history of multiple abdominal issues is a red herring in this context—his current presentation is clearly related to the witnessed trauma with a benign examination and improving symptoms. 1

Reassurance Strategy

Address the patient's and mother's anxiety directly:

• The mechanism (swinging hammer) caused superficial trauma evidenced by the bruising pattern 1
• Serious injuries from blunt trauma present with progressive symptoms, not improving ones 1
• The 48-hour mark with symptom resolution is reassuring for ruling out delayed complications 1
• Mild pain with deep breathing is consistent with chest wall/rib contusion, not intra-abdominal pathology 1

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