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Bedside renal ultrasound demonstrated a right renal cyst with echogenic debris consistent with a hemorrhagic cyst (red arrow). In addition, a computed tomography (CT) scan of the abdomen and pelvis revealed a 4mm non-obstructing right renal stone and bilateral renal cysts. The CT also confirmed the ultrasound finding of a right renal cyst with mild perinephric stranding possibly consistent with a hemorrhagic cyst.
A bedside point of care ultrasound FAST exam was performed revealing a left subcapsular renal hematoma. The hematoma was a non-compressing hematoma, evidenced by preserved renal contour with the hematoma labeled with a red H and the normal renal contour labeled with a green K. Additionally, cortical necrosis and ischemia can be characterized by a dark, hypoechogenic renal cortex on ultrasonography with a decrease in flow to the cortex on color doppler which was not seen on this patient, providing further evidence that the hematoma was non-compressing. The hematoma was concluded to be an acute process due to its hypoechoic appearance with some mixed ultrasonographic echoes caused by the early deposit of fibrin.
The MRI showed extensive spondylotic changes suggestive of malignancy (red arrows) with severe spinal canal stenosis at the lumbar spine L3-L4 (purple arrows) level contributing to clumping of cauda equina nerve roots and severe bilateral neuroforaminal narrowing with diffuse disc bulges abutting the exiting nerve roots at multiple levels. Findings also showed a hypo-attenuated tumor (blue arrow) and hyper-attenuated loculated tumor (green arrow) consistent with renal cell carcinoma (RCC).
The patient had a witnessed episode of isolated left upper extremity jerking, shown in the video, during which she was completely awake and conversant. Lab results were significant for serum glucose of 1167 mg/dL, no anion gap, and negative serum/urine ketones. She had a computed tomography (CT) of the head that did not show any acute pathology, and underwent a brain magnetic resonance imaging (MRI) without any signs of stroke or other pathology, shown below.