A 65-year-old woman comes to the clinic due to markedly decreased urine output for the past 24 hours. The patient underwent coronary angiography by the physician's colleague 5 days ago and was discharged the next day in stable condition. Medical conditions include type 2 diabetes mellitus, hypertension, and coronary artery disease. Temperature is 37 C (98.6 F), blood pressure is 140/92 mm Hg, pulse is 88/min, and respirations are 14/min. Laboratory results show creatinine of 3.4 mg/dL and blood urea nitrogen of 40 mg/dL. Acute tubular necrosis secondary to the contrast used during angiography is suspected. Review of the medical chart before and after the procedure reveals that the patient did not receive adequate hydration prior to angiography. The patient is very concerned and asks why she is unable to urinate. Which of the following is the most appropriate response?

Question

A 65-year-old woman comes to the clinic due to markedly decreased urine output for the past 24 hours.  The patient underwent coronary angiography by the physician's colleague 5 days ago and was discharged the next day in stable condition.  Medical conditions include type 2 diabetes mellitus, hypertension, and coronary artery disease.  Temperature is 37 C (98.6 F), blood pressure is 140/92 mm Hg, pulse is 88/min, and respirations are 14/min.  Laboratory results show creatinine of 3.4 mg/dL and blood urea nitrogen of 40 mg/dL.  Acute tubular necrosis secondary to the contrast used during angiography is suspected.  Review of the medical chart before and after the procedure reveals that the patient did not receive adequate hydration prior to angiography.  The patient is very concerned and asks why she is unable to urinate.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

This patient likely has contrast-induced acute kidney injury (AKI), and her risk may have been unnecessarily increased due to lack of periprocedural intravenous hydration. Discussing a potential medical mistake made by a colleague can be awkward, especially when the patient or family is pressing for detailed information. Nevertheless, the physician should discuss the essential truth with the patient in a tactful and concise manner. Ideally, patient discussions regarding an adverse outcome should be conducted by the physician who had primary responsibility for the initial intervention. If the physician who performed the procedure is unavailable, a complete and detailed explanation may not be possible. Therefore, a brief and honest explanation should be provided to the patient immediately ("This may be related to your recent angiography"), with the assurance that a definitive answer will be provided once the matter has been fully discussed with the colleague. In the meantime, appropriate care and follow-up for the acute complication should be provided. (Choice A) AKI can be associated with administration intravenous contrast agents, and the risk may be greater in patients with diabetes mellitus. However, this only increases the importance of proper care and does not excuse a serious medical mistake. (Choice B) This response completely evades the patient's direct question and is not appropriate. Even though the physician has not had the opportunity to discuss the patient's care with the colleague, a brief acknowledgment of the potential relationship of the procedure to the complication should be made. (Choice C) Claiming that the cause of this patient's condition may never be known is deceptive, particularly since the sequence of events has a potentially clear explanation. The physician should discuss the basic facts of the case in a tactful but honest way. (Choice D) Although intravenous hydration was not given prior to the procedure, additional information should be obtained from the responsible physician before determining that it was mistake; there might have been other reasons for not giving intravenous fluids. Also, patients can develop AKI following intravenous contrast even with appropriate precautionary measures. Educational objective: Patient discussions regarding treatment complications should ideally be conducted by the physician who had primary responsibility for the initial intervention. If that physician is unavailable, a brief and honest explanation should be provided to the patient by the covering physician, with the assurance that a definitive answer will be provided once the matter has been fully discussed with the colleague.

A 65-Year-Old Woman Comes to the Clinic Due to Markedly