A 20-year-old woman presents to your office with a chief complaint of abdominal pain. Upon further questioning, the woman reveals that she was sexually assaulted at a party 3 weeks ago by a male friend whom she recently started dating. She tells you that she has not revealed this to anyone else, and has not informed the police because she was drinking. Her abdominal and pelvic examinations are normal.
Which of the following is the best management to offer this patient?
The physician’s responsibility in the care of a rape victim includes medical, medical-legal, and emotional support. The physician’s medical responsibilities include treatment of injuries, testing, and prevention and treatment of both infections and pregnancy. This patient has a normal examination, and a CT is not indicated. She should be tested for sexually transmitted infections and given prophylactic antibiotics to treat such diseases. A pregnancy test should be performed, and if negative, she should be offered emergency contraception. Since emergency contraception should be given within 72 hours of the event, this patient is not a candidate for emergency contraception. Even though there can be longstanding psychological consequences of rape, antidepressants are not indicated at this time for this patient.
An 18-year-old undergraduate student presents to the emergency department at 5 am on a Saturday morning reporting that she was the victim of sexual assault while attending a fraternity party the evening before. When you first encounter this patient to take a detailed history, she remains very calm, but has trouble remembering the details of the experience. She reports that she has not used any alcohol or illicit drugs.
The victim’s inability to think clearly and remember things is best explained by which of the following?
Rape trauma syndrome is the medical term that refers to the response that survivors have to rape. It is considered to be the natural response of a psychologically well person to the traumatic event. As part of the rape trauma syndrome, victims of sexual assault may appear calm, tearful, or agitated, or they may demonstrate a combination of these emotions. In addition, victims of sexual assault may suffer an involuntary loss of cognition where they cannot think clearly or remember things. The immediate or acute phase of the rape trauma syndrome can last for hours to days. It is associated with a paralysis of the victim’s usual coping mechanisms. The victim’s response may be complete emotional breakdown or well-controlled behavior. The actual reaction of the victims will depend on many factors, including use of force, length of attack or how long they were held against their will, and their relationship to the attacker (stranger versus someone close to them). The victim is usually disorganized immediately after the assault and has both physical and emotional complaints.
Which of the following is most likely a component of the acute phase of the rape trauma syndrome?
You are called to the emergency department to evaluate an 18-yearold woman for a vulvar laceration. She is accompanied by her mother and father. The father explains that the injury was caused by a fall onto the support bar on her bicycle. You interview the woman alone and find out that her father has been sexually assaulting her.
Which of the following statements best describes injuries related to sexual assault?
Injuries occur in 12% to 40% of sexual assault victims. Most occur when the victim is restrained or physically coerced into the sexual act. Most are minor and require simple repair; only 1% require major surgical repair and hospitalization. The physician should evaluate for injuries such as abrasions, bruises, scratches, and lacerations on the neck, abdomen, back, buttocks, and extremities, as well as the genital area. Lacerations of the vagina and vulva are common in children, virginal victims, and postmenopausal women.
You are evaluating a 19-year-old victim of sexual assault in the emergency department. As a physician, your legal requirement includes which of the following?
When possible, the acute evaluation of sexual assault victims should be undertaken by someone with specific training to care for victims of sexual assault. Complete evaluations are time intensive and require several hours. Your legal requirement as a physician evaluating a sexual assault victim includes documentation of history, examination and notation of injuries, and collection of clothing and vaginal, rectal, oropharynx, pubic hair samples, and fingernail scrapings, as appropriate, for testing. The history should focus on precise details of the sexual assault, and should be obtained in a sensitive and supportive environment. The examination should describe emotional state, and should document any evidence of trauma. The forensic evaluation requires informed consent. Forensic specimens must be submitted to the proper authorities in a timely manner. You must submit any specimens to forensic authorities and receive a receipt for the patient’s chart. Since rape and assault are legally defined terms, they should not be stated as a diagnosis. The CDC recommends that the following laboratory tests be considered to evaluation for sexually transmitted infections in victims of sexual assault. These are as follows: gonorrhea and chlamydia nucleic acid amplification tests from the vagina, anus, and throat; DNA probe for trichomonas vaginalis; and serum testing for hepatitis B, syphilis, and HIV. Whether or not to test for these infections should be individualized. The CDC also recommends antibiotic prophylaxis, since many assault victims will not return for follow up. Prophylaxis should be directed at treating the most common infections, including gonorrhea, chlamydia, and trichomonas. The recommended treatment is ceftriaxone 250 mg intramuscularly in a single dose plus azithromycin 1 g orally in a single dose, plus metronidazole 2 g orally in a single dose. Post-exposure hepatitis B vaccination and HIV prophylaxis are also recommended. “Emergency contraception” (medication prophylaxis) to prevent pregnancy should be offered to women following sexual assault. A pregnancy test should be performed to exclude pregnancy.
Nausea is a very common side effect with combination estrogen/progestin pills used for emergency contraception. Plan B, a progestin-only form of emergency contraception, has a much lower rate of nausea and is better tolerated, making it the preferred choice. Prophylaxis can be given up to 72 hours after the assault, but has been shown to be effective up to 5 days after the rape. Emergency contraception has efficacy rates of 74% to 89%. Patients should be informed that their next menses may be delayed and counseled to get a pregnancy test if it is delayed more than 2 weeks. A copper IUD can be inserted for emergency contraception but should be avoided until active infection can be ruled out. Following the assault, the patient should receive follow-up counseling within 24 to 48 hours, and subsequent follow-up appointments can be arranged at 1 and 4 weeks. The patient should not leave without plans for follow-up. Psychosocial support is an important part of recovery for assault survivors. The reorganization phase of the rape trauma syndrome involves long-term adjustments and may last for months to years. Flashbacks and nightmares may continue and phobias may develop. Victims may also make many new lifestyle changes (eg, moving, making new friends, getting a new job). This is an attempt by victims to regain control over their lives. Medical and counseling care should remain nonjudgmental, sensitive, and attuned to the patient’s overall well-being. It is important for the patient to continue counseling during this time for full recovery to be achieved.
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