26.2 Acute Physical & Sexual Assault Care

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

26.2 Acute Physical & Sexual Assault Care

Key Takeaways Explain This Topic AI

Trauma-informed care is the foundational standard for acute sexual assault management, prioritizing patient autonomy, dignity, and informed consent; the patient retains the absolute right to accept, decline, or pause any portion of the physical examination or forensic evidence collection at any point without forfeiting medical care.

The Sexual Assault Forensic Examination (SAFE / 'rape kit') can recover viable male DNA and forensic trace evidence up to 72 to 120 hours (3-5 days) following an assault; maintaining a documented, unbroken chain of custody with tamper-evident packaging and locked storage is mandatory to ensure forensic evidence is legally admissible.

Mandatory reporting laws apply universally across all jurisdictions for suspected sexual abuse of minors (<18 years) and vulnerable or dependent adults/elders; conversely, for competent, emancipated adults without penetrating firearm or deadly weapon trauma, reporting to law enforcement is NOT mandatory in most states, upholding survivor privacy, confidentiality, and autonomy.

Comprehensive post-assault antimicrobial prophylaxis against sexually transmitted infections includes: ceftriaxone 500 mg IM single dose (gonorrhea), doxycycline 100 mg PO BID for 7 days (chlamydia), and metronidazole 500 mg PO BID for 7 days (trichomoniasis); hepatitis B vaccine (+ HBIG if assailant HBsAg status is positive or unknown and survivor is unvaccinated) should be administered.

Emergency pregnancy prevention requires oral ulipristal acetate 30 mg or copper IUD placement within 120 hours (5 days), or levonorgestrel 1.5 mg within 72 hours; HIV non-occupational post-exposure prophylaxis (nPEP) must be initiated within 72 hours using a 28-day 3-drug antiretroviral regimen (e.g., tenofovir-emtricitabine plus dolutegravir).

Last updated: September 2026

Trauma-Informed Care Principles & Initial Stabilization

Sexual assault is a profound physical and psychological violation affecting millions of individuals, with approximately 1 in 5 women and 1 in 14 men experiencing completed or attempted rape in their lifetimes. Patients presenting to primary care clinics, urgent care centers, or emergency departments following acute sexual assault require an integrated, highly compassionate response that simultaneously addresses acute medical stabilization, forensic evidence recovery, infectious disease prophylaxis, pregnancy prevention, and psychological crisis intervention.

The Foundational Tenets of Trauma-Informed Care

Trauma-informed care shifts the clinical paradigm from "What is wrong with you?" to "What happened to you?" In acute assault care, trauma-informed practice is operationalized through specific clinical behaviors:

Patient Autonomy and Control : Traumatic assault strips victims of control. Restoring agency is the primary therapeutic goal. The patient has the absolute right to accept, decline, or pause any portion of the interview, physical examination, photography, or evidence collection. Clinicians must explicitly state: "You are completely in charge of this visit. We will only do what you want to do, and you can tell me to stop or pause at any second."

Informed Consent at Every Step : Explain the precise clinical rationale and physical sensation of every maneuver before touching the patient (e.g., "Next, I am going to gently examine your outer skin with this soft cotton swab; is that okay?" ).

Patient Comfort & Chaperone / Advocate Presence : Provide a private, quiet room. Offer a specialized Sexual Assault Nurse Examiner (SANE) or a dedicated community-based sexual assault victim advocate. Allow a trusted family member or friend to remain present if desired by the patient.

Non-Judgmental, Empathic Communication : Avoid questions that imply victim blame, such as inquiring why the patient was in a certain location, what clothing they wore, or why they delayed seeking medical care. Validate their courage in seeking evaluation.

Trauma-Informed Physical Positioning : Avoid leaving the patient in a lithotomy position with feet in stirrups for any longer than strictly necessary for speculum examination. Keep the patient draped comfortably throughout the encounter.

Immediate Medical Triage: Life-Threatening Injuries First

Forensic evidence collection must never supersede emergency stabilization. Clinicians must immediately assess:

Airway, Breathing, Circulation : Evaluate for signs of hemorrhagic shock, internal hemorrhage, or blunt abdominal trauma.

Non-Genital Physical Trauma : Screen carefully for signs of strangulation / asphyxiation (petechiae across the conjunctivae, facial swelling, hoarseness, dysphagia, stridor, odynophagia, neck tenderness). Strangulation carries a high risk of delayed carotid artery dissection, stroke, and progressive laryngeal edema, warranting emergent CT angiography of the neck.

Intoxication & Head Trauma : Assess Glasgow Coma Scale (GCS), screen for closed head injury, intracranial hemorrhage, and drug-facilitated sexual assault (DFSA).

• The Sexual Assault Forensic Examination (SAFE) & Legal Framework
• Timing & Forensic Viability Window

The Sexual Assault Forensic Examination (SAFE), colloquially known as a 'rape kit,' is a standardized evidence collection kit designed to recover biological and physical trace evidence for criminal prosecution.

Temporal Window : Forensic DNA evidence (spermatozoa, seminal fluid, non-sperm male epithelial cells, touch DNA) is reliably recoverable from anogenital cavities for up to 72 to 120 hours (3 to 5 days) following penetration. After 72 hours, sperm viability in the vagina decreases, but modern polymerase chain reaction (PCR) and short tandem repeat (STR) DNA profiling frequently detect non-sperm male DNA up to 120 hours. On external unwashed skin, dried biological fluids can persist up to 7 days .

Patient Instructions Prior to Exam : Survivors should be gently advised (if calling prior to arrival) to avoid showering, bathing, douching, brushing teeth, changing clothes, urinating, or defecating before the examination. However, the exam should NEVER be refused or omitted simply because the patient has showered or delayed presentation within the 120-hour window .

Step-by-Step Evidence Collection Protocol

Chain of Custody : Meticulous documentation of every individual who collects, handles, packages, and transfers the forensic kit. All evidence containers must be labeled with tamper-evident tape, signed, dated, and stored in a locked, temperature-controlled, secure refrigerator until official transfer to law enforcement.

Clothing Collection : Have the patient undress while standing over a clean paper sheet to capture any dislodged trace debris (hairs, fibers). Package each piece of clothing individually in breathable paper bags (never plastic bags, as trapped moisture promotes bacterial growth and enzymatically degrades DNA).

External Body Examination & Wood's Lamp : Inspect the entire body under natural light and with an ultraviolet (Wood's) lamp or alternate light source (ALS) to detect fluorescent dried seminal fluid, saliva, or urine. Swab suspicious areas using sterile water-moistened cotton swabs.

Anogenital Swabs : Systematic swabbing of the perianal skin, rectal canal, vulva, vaginal vault, and ectocervix using designated kit swabs and smear slides.

Fingernail Scrapings : Scrape under the patient's fingernails using sterile wooden scrapers to collect defensive touch DNA from the assailant.

Toxicology Screening for Drug-Facilitated Sexual Assault (DFSA) :

Suspect DFSA when the patient experiences unexplained amnesia, sudden unconsciousness, rapid intoxication disproportionate to alcohol intake, or awakening in unfamiliar surroundings.

Common Agents : Flunitrazepam (Rohypnol), Gamma-hydroxybutyrate (GHB), Ketamine, Zolpidem, Alprazolam/Clonazepam, and Ethanol.

Sample Collection : Collect urine (100 mL) and blood (two grey-top sodium fluoride tubes) as early as possible. GHB is cleared rapidly and becomes undetectable in urine after 12 hours (and blood after 6-8 hours); flunitrazepam metabolites persist in urine for 72 to 96 hours.

Mandatory Reporting Laws: Adults vs. Vulnerable Populations

A critical board examination distinction exists between mandatory reporting obligations across different patient cohorts: MANDATORY REPORTING DECISION MATRIX

• Patient Demographics
• │
• ┌─────────────────────────────┴─────────────────────────────┐
• ▼ ▼
• VULNERABLE POPULATIONS COMPETENT ADULTS
• Children (<18 years of age) (Aged ≥18, cognitively intact)
• Vulnerable / Dependent Adults (No penetrating weapon trauma)
• Elders (>60-65 years, state-dependent) │
• │ ▼

▼ MANDATORY REPORTING: NO!

• MANDATORY REPORTING: YES! • In the vast majority of states, reporting
• Reporting to Child Protective Services (CPS) sexual assault of an adult is NOT mandatory

or Adult Protective Services (APS) is without patient consent.

MANDATED BY LAW in all 50 states. • Breaching confidentiality without consent

• Patient / parent consent is NOT required. violates patient autonomy and trust.

• Failure to report constitutes a misdemeanor/crime. • Exception: Gunshot wounds / stab wounds.

Preserving Adult Survivor Agency : For competent adults, clinicians must inform them of their options:

Report to Law Enforcement : Police are contacted, an investigation begins, and the forensic kit is transferred immediately to the forensic crime laboratory.

Anonymous / 'Jane Doe' Evidence Collection : The forensic kit is collected and sealed under an anonymous tracking number without notifying police or documenting patient identifiers on the kit. The evidence is stored securely (often for 2 to 5 years, depending on state statute), allowing the survivor time to process the trauma and decide later whether to participate in criminal prosecution.

Medical Prophylaxis Protocols: Pregnancy, STIs, Hepatitis B & HIV

Medical prophylaxis must be offered to every survivor of sexual assault regardless of whether they consent to forensic evidence collection. Prophylaxis addresses four critical threats: pregnancy, bacterial sexually transmitted infections, Hepatitis B virus, and Human Immunodeficiency Virus.

1. Emergency Contraception (Pregnancy Prevention)

All female survivors of reproductive potential with female internal genitalia who experienced penile penetration within the past 120 hours must be evaluated for emergency contraception. Verify non-pregnant status first via urine point-of-care beta-hCG.

Ulipristal Acetate (Ella, 30 mg PO single dose) :

Mechanism : Selective progesterone receptor modulator that postpones or inhibits follicular rupture (ovulation), even when luteinizing hormone (LH) has already started to surge.

Efficacy Window : Highly effective up to 120 hours (5 days) post-assault.

Clinical Advantage : Significantly more effective than levonorgestrel across the entire 120-hour window, and maintains superior efficacy in women with elevated body mass index ( BMI >25 to 30 kg/m² ).

Levonorgestrel (Plan B One-Step, 1.5 mg PO single dose) :

Mechanism : Synthetic progestin that prevents ovulation.

Efficacy Window : Most effective when taken within 72 hours (3 days) ; efficacy declines sharply between 72 and 120 hours.

Limitation : Significantly reduced efficacy in women with BMI >25 kg/m² and largely ineffective in women with BMI >30 kg/m².

Copper Intrauterine Device (Copper IUD / Paragard) or 52 mg Levonorgestrel IUD :

Timing : Inserted within 120 hours (5 days) of assault.

Efficacy : The most effective method of emergency contraception (>99% efficacy) , regardless of patient body weight or BMI, while providing ongoing long-term contraception.

2. Empiric Sexually Transmitted Infection (STI) Antimicrobial Prophylaxis

Because testing at the time of assault only identifies pre-existing infections (and cannot detect newly inoculated organisms during the incubation window), the Centers for Disease Control and Prevention (CDC) recommends routine empiric antimicrobial prophylaxis rather than waiting for laboratory culture/NAAT results: CDC POST-ASSAULT STI PROPHYLAXIS REGIMEN

• TARGET ORGANISM GUIDELINE-DIRECTED REGIMEN
• ─────────────────────────────────────────────────────────────────────────────
• Neisseria gonorrhoeae Ceftriaxone 500 mg IM in a single dose
• (Administer 1,000 mg IM if patient weight ≥ 150 kg)
• ─────────────────────────────────────────────────────────────────────────────
• Chlamydia trachomatis Doxycycline 100 mg PO twice daily for 7 days
• (Preferred over azithromycin due to higher cure rates;
• If pregnant: Azithromycin 1 g PO in a single dose)
• ─────────────────────────────────────────────────────────────────────────────
• Trichomonas vaginalis Metronidazole 500 mg PO twice daily for 7 days

(Preferred over single 2 g dose; Alternative:

• Tinidazole 2 g PO in a single dose)
• 3. Hepatitis B Virus (HBV) Immunoprophylaxis

Unvaccinated or Incompletely Vaccinated Victims : Administer the first dose of the Hepatitis B vaccine (1.0 mL IM) at the time of initial evaluation, with arranged follow-up doses at 1 and 6 months.

Indication for Hepatitis B Immune Globulin (HBIG) : If the assailant is known to be Hepatitis B surface antigen (HBsAg) positive , or if the assailant is of unknown status and the victim is unvaccinated, administer HBIG 0.06 mL/kg IM simultaneously with the first dose of the Hepatitis B vaccine (injected at a different anatomical site, e.g., opposite deltoid or anterolateral thigh). HBIG must be administered within 14 days of exposure (ideally within 24 hours).

Previously Vaccinated Victims with Documented Immunity : No prophylaxis required.

4. HIV Non-Occupational Post-Exposure Prophylaxis (nPEP)

Sexual assault involving genital, anal, or oral mucosal contact carries a quantifiable risk of HIV transmission, which surges in the presence of mucosal lacerations, genital bleeding, multiple assailants, or an assailant known to be living with HIV.

The Critical 72-Hour Window : nPEP must be initiated as soon as possible, ideally within 2 hours, and no later than 72 hours post-exposure . Clinical and animal studies demonstrate that antiretroviral efficacy drops to zero if initiated beyond 72 hours.

Duration : A complete, uninterrupted 28-day course of a 3-drug antiretroviral regimen is mandatory.

Preferred 3-Drug Regimen for Adults and Adolescents with Normal Renal Function (CrCl ≥50 mL/min) :

• Tenofovir Disoproxil Fumarate (TDF) 300 mg / Emtricitabine (FTC) 200 mg (Truvada) 1 tablet PO once daily; PLUS
• Dolutegravir (Tivicay) 50 mg PO once daily; OR

Alternative Third Agent : Bictegravir (co-formulated as Biktarvy [BIC 50 mg / FTC 200 mg / TAF 25 mg] 1 tablet daily) or Raltegravir (Isentress) 400 mg PO twice daily.

Baseline & Follow-up Laboratory Surveillance :

Baseline : Rapid 4th-generation HIV antigen/antibody test (if positive, patient has pre-existing HIV and does not receive nPEP; refer to infectious disease), pregnancy test, baseline serum creatinine, and AST/ALT.

Follow-up : Repeat HIV testing at 4 to 6 weeks and 3 months post-exposure.

5. Tetanus Prophylaxis

Administer Tetanus toxoid-containing vaccine (Td or Tdap 0.5 mL IM) if the patient has sustained skin abrasions, bites, or lacerations and has not received a tetanus booster within the preceding 5 years (for contaminated wounds) or 10 years (for clean wounds).

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