A 21-year-old woman is brought to the emergency department by her roommate. During a first date a week ago, the patient blacked out after a single glass of wine. She woke up naked in her date's apartment and could not remember how she got there. The patient has been anxious and embarrassed about the event and reluctantly told her roommate what happened after she was found crying in the bathroom today. She does not want to involve the police because she wants to "move on." The patient's last menstrual period was 3 weeks ago. Vital signs are normal and physical examination is unremarkable. Urine pregnancy testing is negative. The patient is prescribed emergency contraception and postexposure prophylaxis for sexually transmitted infections. Which of the following is the best next step in management of this patient?

Question

A 21-year-old woman is brought to the emergency department by her roommate.  During a first date a week ago, the patient blacked out after a single glass of wine.  She woke up naked in her date's apartment and could not remember how she got there.  The patient has been anxious and embarrassed about the event and reluctantly told her roommate what happened after she was found crying in the bathroom today.  She does not want to involve the police because she wants to "move on."  The patient's last menstrual period was 3 weeks ago.  Vital signs are normal and physical examination is unremarkable.  Urine pregnancy testing is negative.  The patient is prescribed emergency contraception and postexposure prophylaxis for sexually transmitted infections.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d780_283f_bc81_5f59aa5ba520_MD0003_00 This patient is likely a victim of date rape. Rape is sexual assault involving unwanted vaginal, oral, or anal penetration through force or lack of consent. Most cases occur between acquaintances and up to half involve intoxication with alcohol or the use of date rape drugs (eg, flunitrazepam [Rohypnol]) that cause loss of consciousness and amnesia, as in this patient. Among adolescents and young adults, there are multiple cultural myths about date rape, including that it is not "real" rape and that "by agreeing to go home with a man, a woman is agreeing to sex." Because of these myths, date rape victims are more likely to feel partially responsible for their assault, which can lead to long-term psychologic consequences ranging from decreased appetite and sleep disturbances to posttraumatic stress disorder and suicidality. Therefore, management includes both medical care (eg, postexposure prophylaxis, emergency contraception) and psychosocial counseling, which should take place as soon after the assault as possible (Choice D). Patients should be reassured that they were not responsible and be provided multiple forms of support (eg, support group referral, individual therapy). (Choice A) Date rape prevention may be discussed at the annual well-woman visit, but this advice is insensitive immediately after an assault and places blame on the patient. (Choice B) Although mandatory reporting occurs for child and elder abuse, sexual assault of an adult does not in most jurisdictions. In addition, notifying the police against this patient's wishes is inappropriate. (Choice C) Urine toxicology can identify date rape drugs, but testing must be performed soon after an assault due to a short half-life. Because this patient's assault was a week ago, testing is unlikely to be effective. (Choice F) Antidepressant therapy may be indicated in patients who develop depression or posttraumatic stress disorder due to sexual assault; however, additional psychosocial evaluation is required in this patient before starting medical therapy. Educational objective: Victims of sexual assault (eg, date rape) are at risk for long-term psychologic consequences (eg, posttraumatic stress disorder). Therefore, they should be offered psychosocial counseling in addition to medical care (eg, postexposure prophylaxis, emergency contraception). References: Sexual assault of women. (http://www.ncbi.nlm.nih.gov/pubmed/20148503) ACOG committee opinion no. 777 summary: sexual assault. (http://www.ncbi.nlm.nih.gov/pubmed/30913196)

A 21-Year-Old Woman Is Brought to the Emergency Department by Her