Exercise 6 case study answers

Prescribing Treatment for Survivors of Sexual Assault - Answers

Case Study 1:
An adult woman survivor comes to the clinic 36 hours after being sexually assaulted. She
states she wants all available treatment. Her physical exam is completely normal. She
states she has no allergies that she knows of. You have no Postinor, however, you do have a
combined oral contraceptive with estrogen estrodiol 50 μg and levonorgestrel 250 μg.

The treatment offered to the woman should include:
To prevent
Give treatment (include dosage)
Combined oral contraceptive, 2 pills now and 2 pills in 12 Azithromycin 1g stat or doxycycline 100 mg bid x 7d
benzathine penicillin 2.4 MIU According to local STI protocol. Preferably stat oral dose. i.e cefixime 400 mg stat. metronidazole 2g stat (we did not discuss this in the training but depending on local prevalence and guidelines may be indicated) Hepatitis B vaccine, 1st dose stat, #2 in 30 days, #3 in 6 azithromycin (1g) also gives good coverage for chancroid. Tetanus vaccination if not completely immunized
What points would you include in your counseling and care plan?
• Reassure her that she was not to blame for the assault. She has done the right thing by
seeking care and many of the health risks can be reduced. It is ok to feel emotional, angry, sad, confused. • Evaluate for pregnancy risk, offer test. If already pregnant not due to assault. ECP do not cause abortion. Can cause nausea and vomiting. Return to clinic if she vomits within 2 hours after dose (consider giving extra dose so she does not have to come back. Get follow up pregnancy test if menses do not come as expected. • Take meds with food to ease upset stomach. Take full course. Do not stop without seeking medical advice. PEP in particular can cause nausea, weakness, fatigue. These symptoms will go away at the end of the treatment. • Offer HIV test. If not done now should be done within 2 weeks. Testing to check if she was already infected. PEP does not treat already existing infections. Need to repeat test in 3 - 6 months. Use condoms until negative test. • If symptoms of vaginal soreness, itching, pain, painful urination develop she should seek medical care immediately (especially if you did not treat for trichomonas or any of the other STIs). • Offer first dose of Hep. B vaccine and counsel on where and when to get next 2 doses. What other services would you offer or refer her to?
• Follow up in 1 week to see how she is tolerating the medicine.
• Give referrals for HIV testing if not done today and cannot be done at this facility. • Refer to support group/women’s center/counselor and to a legal support center if

Case Study 2:
A 5 year old boy comes to the clinic 70 hours after being sexually assaulted. The assault
included anal penetration. The boy is crying and can’t sit normally. He has no other injuries.
His mother states she wants all available treatment. She states he has no allergies that she
knows of. He weighs 16.5 kgs.
The treatment offered to the boy should include:
To prevent
Give treatment (include dosage)
azithromycin 350 (or 500 if not available) stat or
erythromycin 200 mg qid for 7 days
Nothing if azithromycin given or
benzathine penicillin 800,000 IU stat IM or
Erythromycin for 14 days (same daily dose as above)
According to local protocol (preferably stat dose orally) for example cefixime 150 mg Hepatitis B vaccine, 1st dose stat, #2 in 30 days, #3 in 6 months Other STIs according to your azithromycin also gives good coverage for chancroid. setting HIV/AIDS zidovudine 100mg capsule tid for 28 days lamivudine 75 mg (1/2 of a 150 mg tablet) bid for 28 days What points would you include in your counseling and care plan?
• The child is not to blame for the assault. Will need extra attention, patience and
affection over next weeks, months. Bedwetting, nightmares, etc., part of normal reaction. Needs to continue daily routine, school. • Evaluate for risk of repeated abuse and work to ensure safety. Report to authorities if in child’s best interest. Follow local laws. • Give stool softeners, warm soaks to reduce anal discomfort, avoid hold stool. • Give meds with food to ease upset stomach. Take full course. Do not stop without seeking medical advice. PEP in particular can cause nausea, weakness, fatigue. These symptoms will go away at the end of the treatment. • Needs HIV test in 3 - 6 months. Normal precautions against infection are enough during this period. No risk of infection to other children, family members. • Evaluate whether he is already fully immunized against tetanus and give if needed. • Offer first dose of Hep. B vaccine and counsel on where and when to get next 2 doses. What other services would you offer or refer the child and his mother to?
• Refer to support group, other social services, authorities.
• Follow up in 1 week to see how he is tolerating the medicine. • Give referrals for HIV testing
Case Study 3:
An 11 year old girl is brought to the clinic by her aunt who is her guardian. She reports
multiple sexual assaults by a group of 5 soldiers 4 days ago. Her aunt is very concerned
about HIV. Wants all possible treatment. Her weight is 35 kg. On examination you find
multiple bruises on breasts, healing lacerations around introitus and anal tears. When she
takes off her skirt you see that she has wet herself.
To prevent
Give treatment (include dosage)
azithromycin 750mg stat or erythromycin 500mg qid for 7d
benzathine penicillin 1.8 MIU
According to local STI protocol. Preferably stat oral dose.
i.e cefixime 280 mg stat. If not available give ceftriaxone 125mg stat metronidazole 2g stat (we did not discuss this in the training but depending on local prevalence and guidelines may be indicated) Hepatitis B vaccine, 1st dose stat, #2 in 30 days, #3 in 6 azithromycin (1g) also gives good coverage for chancroid.
What points would you include in your counseling and care plan?
• Reassure her that she was not to blame for the assault. She has done the right thing by
seeking care and many of the health risks can be reduced. It is ok to feel emotional, angry, sad, confused. Explain to guardian that she will need extra attention, patience and affection over next weeks, months. Bedwetting, nightmares, etc., part of normal reaction. Needs to continue daily routine, school. • Evaluate her safety and report to authorities if in her best interest. Follow local laws. • Even if she has not yet started menstruating, she may be at risk for pregnancy. ECP does not cause abortion and it will not affect her ability to get pregnant in the future. It may cause some spotting. • Take meds with food to ease upset stomach. Take full course. Do not stop without • She is not a candidate for HIV PEP. Her risk of being infected is small but she should be tested in 3 – 6 months to check her status. Evaluate for risk of prior HIV infection and offer HIV test is appropriate. The disease is transmitted through blood or sex. Friends or family members are not at risk. • If symptoms of vaginal soreness, itching, pain, painful urination develop she should seek medical care immediately (especially if you did not treat for trichomonas or any of the other STIs). • Evaluate whether she is already fully immunized against tetanus and give if needed. • Offer first dose of Hep. B vaccine and counsel on where and when to get next 2 doses. What other services would you offer or refer her to?
• Follow up in 1-2 weeks.
• Give referrals for HIV testing in 3 months if it cannot be done at this facility. • Refer to support group/women’s center/counselor and to a legal support center if
Case Study 4:
A 51 year old women reports being severely beaten and sexually abused by a soldier 2 days
ago. Perpetrator unable to achieve sufficient erection for vaginal penetration. Survivor was
forced to perform oral sex on perpetrator who did not achieve erection nor ejaculate. On
examination you find multiple bruises around face and legs and abdomen and lacerations on
forehead and abrasions on elbows. She is very emotional and very concerned about HIV.
She says she wants all possible treatment.
To prevent
Give treatment (include dosage)
azithromycin 1 g stat or
doxycycline 100 mg bd for 7 days Nothing if given azithromycin benzathine penicillin 2.4 MIU
According to local STI protocol. Preferably stat oral dose.
i.e cefixime 400 mg stat. If not available give ceftriaxone 125mg stat
What points would you include in your counseling and care plan?
• Reassure her that she was not to blame for the assault. She has done the right thing by
seeking care. It is ok to feel emotional, angry, sad, confused. • She may have been exposed to an STI during the oral penetration, but the drugs are very effective at preventing disease. Oral exposure has a very low risk of HIV infection. • Evaluate whether she is already fully immunized against tetanus and give if needed. What other services would you offer or refer her to?
• Follow up in 1-2 weeks.
• Refer to support group/women’s center/counselor and to a legal support center if

Source: http://clinicalcare.rhrc.org/docs/exercise_6_case_study_answers.pdf