Hot Seat #258: Are you sure about that?
Posted on: May 4, 2026, by : Brittany Fitzpatrick
Case by Nico Dimenstein, CNH PEM Fellow
17 year old female, history of G/C 4 months ago, treated with resolution of symptoms, here with several days of tactile fevers, body aches, and sores on her lip and in her mouth.
Endorses headache, mild runny nose, cough, and oral ulcers. Has never had oral ulcers before, denies any other areas with ulcerations or pain. Denies dysuria, pyuria, but does endorse scant, mucopurulent vaginal discharge.
Patient is sexually active with two male partners, uses condoms “most of the time”. Last sexually active 3 weeks ago. Menarche at age 14, LMP: started yesterday. Usually lasts 4 days, describes as “moderate”. No forms of birth control, no history of pregnancy.
PMHx: treated for G/C 4 months ago completed course of antibiotics, history of eczema, allergies (seasonal)
Family History: non-contributory
Medications: prn cetirizine, prn acetaminophen
Vital Signs: HR 115, RR 16, BP 114/64, SpO2 99% on RA, 38.2 C
Physical Exam:
General: well appearing, no apparent distress
HEENT: 3 oral ulcers (2x L buccal mucosa, 1x lower lip, L lateral aspect) approximately 2mm with erythematous base, tender to palpation. PERRLA. Conjunctival injection, b/l. Mild clear b/l nasal rhinorrhea with pale nasal turbinates b/l. Mild, shoddy b/l cervical lymphadenopathy.
CV: RRR, no murmurs, rubs or gallops, 2+ pulses radial b/l
RESP: No increased wob, lungs CTAb/ll
ABD: mild tenderness to mid-epigastrium, no rebound or guarding, no pain to RUQ, RLQ, no pain to b/l flanks
GU: exam deferred by patient, offered same-sex provider and different chaperones, still declined.
Neuro: no pain w/flexion, extension, or lateral rotation of neck, no nuchal rigidity, no photo/phonophobia. CN2-12 intact. Normal gait and balance.
Patient declines blood work but is amenable to urine and swabs.
UA/Upreg: both negative
Urine G/C negative
Viral Panel: Rhino/Enterovirus Positive, COVID-19 Positive.
Vaginal Self-Swab: + BV
Oral Swab: *results pending*
After a dose of acetaminophen, your repeat vitals have improved, her HR is now 84, temp 36.8. Mom has arrived and is adamant that the patient get blood work and a urine drug-screen. After re engaging with the patient, she still declines blood work at this time.
After further discussion, patient agrees to blood work but declines examination, again. You obtain a CBC, CMP both of which are normal. Her Rapid HIV Ag/Ab is positive.
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This case forces us to think about when we think it is “okay” to override a teenager’s preferences to accommodate their parent’s requests. I think most of us would agree that the law protects us from performing drug testing without the patient’s explicit consent and sharing those results with the parents. It would be interesting to know what kind of blood work the parent is asking for in this case so that we can have the best shared decision-making with the patient and the family together.
At the conclusion of the case, when the patient’s oral HIV test is positive, I would definitely push for confirmatory serum testing with the patient. At that point, I might acquiesce to the parent’s wishes (if, for example, they were asking for routine blood work like CBC and BMP), because we are “sticking the patient anyway.”