‘Sexual Assault’ on your CCFP Exam

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‘Sexual Assault’ on your CCFP Exam

February 19, 2021 | Family Med Exam Prep | CCFP

We are excited to see so many of you join our spring FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

Just a reminder… pay attention to the questions. Here are our general tips one more time:

1. Pay attention to the questions. Look carefully at how many items you are being asked to list. If the question asks for five items, you will not get more marks if you list eight items; the examiner will look at the first five and allocate marks only for the first five answers – so be careful. On a SAMP, if it is not clearly stated how many items you should list, look at the amount of points/marks being allocated for the question to get an idea of how many answers the examiner may be anticipating you write down.

2. Do not write lengthy answers. Most questions can be answered in 10 words or less!

3. Be specific when writing down investigations (hemoglobin instead of CBC; CT abdomen instead of CT).

4. Remember that trade names and generic names are both acceptable when writing down medications.

5. For more helpful tips, you can refer to CCFP’s SAMP instructions by clicking here.

 

Sexual Assault on your CCFP Exam

An 18 year old girl presents to the emergency department visibly shaken. She reports that her gymnastics coach sexually assaulted her last night after gym practice. She did not report this to the police but confided in her roommate who encouraged her to seek medical care. The assault happened at 8:54 pm last night. (12 points)

1. What should you look for and document on physical examination? (2 points)

    • General body trauma
      • Evidence of strangulation
      • Blunt trauma injury
      • Defensive injuries (e.g. lacerations)
      • Bite marks
    • Anogenital injuries
      • Tears or abrasions of posterior fourchette
      • Bruising/abrasion of labia minora

2. You perform a physical exam and note that there are no anogenital injuries. True or false: this suggests that likely there was no anogenital assault. (1 point)

    • False. Evidence of anogenital injuries is seen in only 50% of cases by simple visual inspection. Colposcopy or blue staining can improve the identification rate to 84%.

3. True or false: it is your legal obligation to collect evidence after a sexual assault. (1 point)

    • False. This is entirely a patient’s choice and requires explicit patient consent.

4. What should you offer the patient after a sexual assault? (5 points)

    • Treatment for Gonorrhea
      • Ceftriaxone or Cefixime
    • Treatment for Chlamydia
      • Azithromycin or Doxycycline
    • Treatment for BV
      • Metronidazole
    • Treatment for Hepatitis B
      • Hepatitis B risk evaluation is recommended
      • If status unknown or negative consider Hepatitis B vaccination x 3 with or without HBIG
      • If HBsAg positive, provide a referral for management
    • Treatment for HIV
      • HIV risk evaluation
      • Offer PEP (e.g. Truvada + Dolutegravir)
      • *Note: choice of PEP will depend on the patient’s risk status and exposure – we recommend discussing with an infectious disease specialist as alternative combinations may be required depending on the source virus. Furthermore, whether to provide PEP will depend on the nature of the assault that occurred (i.e. vaginal, anal, or oral penetration, human bite, etc.)
      • If HIV Ab positive, provide a referral for management
    • Pregnancy prevention
      • Levonorgestrel or Plan B
      • The Yuzpe regimen
      • Mifepristone
      • Ulipristal acetate
      • Insertion of a copper IUD

5. What two vaccines can you offer her in this situation? (2 points)

    • Tetanus (if status unknown or not up to date)
    • HPV vaccination

6. Apart from drug therapy, what else should you make sure you offer the patient, her family, and her friends before you discharge her? (1 point)

    • Crisis intervention with emotional support

Helpful Resources:

Linden et al. (2011). Care of the Adult Patient after Sexual Assault. NEJM 365;9.

Young et al. (Reviewed March 2019). Pocket P.E.P. Clinical management of non-occupational and occupational exposure to blood-borne pathogens. St. Michael’s Hospital.

Sachs et al. (2020) Sexual Assault Infectious Disease Prophylaxis. StatPearls Publishing.

 

 

 

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