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USMLE® Question of the Week

A 19-year-old college student comes to the emergency department due to 1-week history of malaise, fever, and a painful right knee that he says, "I probably just hurt playing football." He has no other symptoms and reports that he has been studying hard and looking forward to an upcoming football game. The patient has a history of depression that is currently treated with fluoxetine. His family history is significant for diabetes mellitus in his father. Temperature is 38.3 C (100.9 F), blood pressure is 130/80 mm Hg, pulse is 108/min, and respirations are 12/min. Physical examination shows a swollen, hot right knee joint that is tender to palpation with a restricted range of motion. The patient is informed about the need for a joint aspiration for possible septic arthritis but refuses, saying, "I prefer not to have anything done with needles; I'll take pain medication and just get some rest." The physician counsels him about the risks, benefits, and alternatives to the aspiration and explains that he can be given a local anesthetic to numb the pain. The patient reports understanding the information but continues to refuse the procedure. Which of the following is the most appropriate next step in management?

A. Admit the patient to the hospital involuntarily as untreated septic arthritis is potentially life-threatening
B. Allow the patient to leave, but counsel him that he can return at any time
C. Allow the patient to leave but inform his coach that he should not play football
D. Obtain a psychiatry consult to assess the patient's depression and his capacity to refuse treatment
E. Tell the patient that his parents must be informed because he is refusing a necessary procedure

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