HISTORY The purpose of the history is to obtain data tactfully about the assault, along with pertinent past medical history, in order to provide proper medical care. The victims should not have to relive every minute detail of the assault and, in fact, an extensively detailed history may hinder subsequent prosecution. 89 A professional, caring manner should be conveyed, and the history should be obtained in private; law enforcement personnel should not be present. Beginning with a general past medical history establishes the victim's trust in the physician. i8,!0,!!,
ASSAULT HISTORY4,81 11
1. Who? Did the victim know the assailant? Was it a single assailant or multiple? How many? Ask about their identity and race.
2. What happened? Was the victim physically assaulted? With what (e.g., gun, bat, or fist) and where? Determine the type and location of physical injuries and appropriately evaluate these injuries. Delineate actual or attempted vaginal, anal, or oral penetration. Did ejaculation occur? If so, where? Was a foreign object used? Was a condom used? This information will direct the physical examination to areas of potential injury.
3. When? When did the assault occur? This will determine the probability of detecting sperm (within 72 h) or acid phosphatase.
4. Where? Where did the assault occur? Corroborating evidence may be found based on the location of the assault.
5. Douche, shower, or change of clothing? Any of these activities performed prior to seeking medical attention may decrease the probability of sperm or acid phosphatase recovery.
MEDICAL HISTORY4,8,1 11
1. Last menstrual period? This will help to determine pregnancy risk.
2. Birth control method? This will also help to determine pregnancy risk.
3. Last consensual intercourse? If the patient has had recent intercourse (less than 3 days) prior to the attack, it may confuse laboratory analysis of sperm, acid phosphatase, and genetic typing.
4. Allergies and prior medical history? This information is necessary before prescribing antibiotics or pregnancy prophylaxis.
5. Prior sexual assault? Has this ever happened to the victim before?
PHYSICAL EXAMINATION48,1 H The physical exam should be performed thoroughly and compassionately. A female chaperone should be present if the examining physician is a man. Document a general medical examination, including vital signs and level of consciousness. Bruises, lacerations, or other signs of trauma should be described in detail; a body map may be useful. As many as 290 percent of rape survivors will have nongenital injuries. -^H.2,13 The examiner should carefully inspect the victim's face, oral cavity, neck, breasts, wrist, thighs, and buttocks. Areas of tenderness should also be recorded. A pelvic examination should be performed, noting any vaginal discharge or genital lacerations or abrasions. Toluidine blue can be used to detect small vulvar lacerations. 4 Lacerations expose the deeper dermis, containing nuclei that absorb this stain. Prior to inserting the speculum, the dye is applied to the posterior fourchette with gauze and wiped away with lubricating jelly. A linear blue stain will highlight the vulvar lacerations. This simple procedure has doubled the reporting of genital lacerations. Colposcopic photographs may reveal other genital injuries, especially to the posterior fourchette. 14
EVIDENTIARY EXAMINATION41011 Informed consent is required prior to evidence collection, and a system to maintain "chain of evidence" should be established. Most hospitals have a prepackaged rape kit with equipment and directions. The least invasive procedures should be performed first, and unnecessary duplication of procedures should be avoided. Any particulate matter should be collected. Examination with a Wood's lamp will reveal semen stains on a patient's body; these areas should be swabbed with a moistened cotton-tipped applicator. Saliva is obtained for secretor status during the oral cavity examination. Fingernail scrapings and hair samples are collected. During the pelvic examination, vaginal swabbings should be collected, along with gonorrhea and chlamydia cultures. Some physicians prefer to treat prophylactically and consider cultures irrelevant. If indicated by history, rectal or buccal swabs for sperm are collected. A rectal examination is performed if anal assault occurred. Emergency physicians should not examine wet mounts for the presence of sperm; this determination should be left to forensic scientists. 910 If blood is present, anoscopy or sigmoidoscopy should be performed. Blood samples are drawn for DNA testing, blood typing, and pregnancy testing. If photographs are used, they should be carefully labeled and given to the police.
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