▁susp icion ▁for ▁spl en ic ▁invol vement . ▁The ▁absence ▁of ▁substantial ▁tra uma ▁cannot ▁exclude ▁the ▁possibility ▁of ▁spl en ic ▁injury , ▁as ▁individuals ▁with ▁a ▁history ▁of ▁spl en om eg aly ▁require ▁less ▁force ▁for ▁tra um atic ▁ru pt ure . ▁ ▁Sever ally ▁ill ▁patients ▁may ▁present ▁with ▁hyp ov ole mic ▁shock ▁manifest ing ▁as ▁t ach y card ia , ▁hyp ot ension , ▁and ▁p all or . ▁Other ▁find ings ▁include ▁tend ern ess ▁to ▁pal p ation ▁in ▁the ▁left ▁upper ▁quadr ant , ▁generalized ▁per it on itis , ▁or ▁referred ▁pain ▁to ▁the ▁left ▁shoulder ▁( Ke hr ▁sign ). ▁Ke hr ▁sign ▁is ▁a ▁rare ▁finding ▁and ▁should ▁increase ▁the ▁susp icion ▁of ▁the ▁per it one al ▁process ▁and ▁possible ▁spl en ic ▁ru pt ure . ▁Some ▁patients ▁also ▁report ▁ple ur it ic ▁left - s ided ▁ch est ▁pain ▁in ▁the ▁setting ▁of ▁a ▁ru pt ured ▁s ple en . ▁Ca ution ▁should ▁be ▁used ▁early ▁in ▁the ▁evaluation ▁of ▁patients ▁with ▁a ▁concerning ▁mechanism ▁of ▁injury , ▁since ▁few ▁sympt oms ▁may ▁be ▁present ▁early ▁in ▁the ▁course ▁of ▁spl en ic ▁ru pt ure . ▁ ▁It ▁is ▁important ▁to ▁ask ▁focused ▁questions ▁regarding ▁previous ▁surg ical ▁history , ▁he p atic ▁disease ▁process , ▁recent ▁in fe ctions , ▁ant ico ag ul ant , ▁asp ir in ▁or ▁non st ero idal ▁anti - infl am mat ory ▁dru