A 19-year-old college student comes to the emergency department due to a 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?

Question

A 19-year-old college student comes to the emergency department due to a 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?

Quizplus · Accepted Answer

There is a very high probability that this patient has septic arthritis, and joint aspiration and fluid analysis are essential to correctly diagnose and treat him. If he refuses the procedure, the first step is to address any issues regarding why he does not want to proceed. If the patient still refuses, he should be allowed to leave based on the principle of autonomy. Patients who have decision-making capacity (are able to understand the risks and benefits of treatment and express a choice) have the right to refuse treatment. The physician should still offer the services and inform the patient that he can always return for diagnosis and treatment. (Choice A) If the situation is an emergency and a patient is incapacitated and cannot make a decision (eg, is unconscious), presumed consent is enough to proceed. However, if a patient has decision-making capacity, this must be respected. (Choices C and E) This patient is not a minor and has a right to confidentiality; threatening to call his parents or calling his coach without permission is unethical and a violation of the physician-patient relationship. The parents or coach could be contacted with permission of the patient. (Choice D) A psychiatry consult would be indicated if the physician believed that the patient's depression could affect his decision-making capacity. However, this patient's depression is adequately treated with medication and there is no evidence that it is influencing his decision. Educational objective: Patients who have decision-making capacity have the right to refuse procedures and treatment. The physician should address any modifiable obstacles to treatment. If the patient still refuses, services should be offered if the patient reconsiders. References: Patients' refusal of recommended treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26194409) Consent and assessment of capacity to decide or refuse treatment. (http://www.ncbi.nlm.nih.gov/pubmed/21537284)

A 19-Year-Old College Student Comes to the Emergency Department Due