emDocs - May 1, 2015 - Author: Brit Long; Editor: Alex Koyfman
"It’s a slow night in the ED, and just as you take a sip of coffee to help wake you up, a 63 year-old male comes in from triage with right flank pain and nausea for two days. He has a history of coronary artery disease, diabetes, hypertension, and atrial fibrillation, but no prior kidney stones. His initial vital signs show HR 82, BP 155/92, RR 22, Sat 98% on room air, and temperature 98F. He denies fevers, PO intolerance, dysuria, abdominal pain, chest pain, or any other symptoms. Exam reveals no CVA tenderness or abdominal tenderness. However, his heart rhythm is irregularly irregular. You have seen this type of patient multiple times before, and you have your differential before you walk into the room.
Labs reveal RBCs in the urine with no WBCs, Cr of 1.4, GFR 62, and normal CBC and lactate. You wheel in your trusty US to the bedside, which reveals normal aorta, normal kidneys with no hydronephrosis, and a normal bladder. CT without contrast of the abdomen/pelvis returns normal, with no stone surprisingly. You were initially sure this patient had a stone or AAA. What could you be missing?
You order a CT abdomen/pelvis with IV contrast after discussing the patient with your radiologist, and the result is surprising: a right-sided renal infarction with extensive thrombus in the right renal artery! With these results, you immediately call your surgeon and interventional radiologist."
http://www.emdocs.net/renal-infarction-pearls-and-pitfalls/