SCE



1. Lead examiner ………….…………………….….

2. Co-examiner …………..……………………….

Candidate Number:

SCENARIO

You are the duty consultant in an urban ED. Scanning the list of patients waiting to be seen, you note the case of a 16 year-old girl, whose triage notes are as follows: “Requesting the morning-after pill. Some bruising on face. Patient explains that she fell yesterday. P 90, BP 110/60, Afeb.” Q1 outside room.

Question 1: You attend to the patient yourself. In confidence, she describes being sexually assaulted the previous day. Outline the key assessment issues.

|Expected Response |Details & Comments | |

|Assessment |Trauma / sexual assault / one day old | |

| |Consent / wishes | |

| |Forensic / medicolegal issues | |

| |Safe for Dx? | |

|Trauma general |Soft tissue, blunt, HI, | |

|Trauma – sexual assault |Genital, perineal, other | |

| |Examination requires expertise | |

| |Absence of signs does not rule out sexual assault | |

| |May be deferred to sexual assault service | |

| | | |

|Risk assessment – exposures |STD prophylaxis / body fluid exposure/assess patient Hep status | |

|Risk assessment - pregnancy |emergency contraception | |

|+/- Forensic specimen collection |Aims: proof of sexual contact, use of force, and assailant’s ID | |

| |Collection and preservation of evidence | |

|Psychological assessment | | |

|Social |Note age / social supports | |

|Confidentiality + Privacy |Pt may be reticent re details | |

|Patient wishes |Police involvement / degree of management / referral eg sex assault centre | |

|Other |Detailed documentation +/- clinical photography | |

Question 2: Outline your approach to STD prophylaxis in this patient.

|Expected Response |Details & Comments | |

|Candidates should risk stratify, and justify choice of Abx regimen. Abx choice would be guided by local susceptibility and resistance patterns. | |

|Difficult risk assessment |High level evidence lacking re risks, organisms | |

| |Difficult to distinguish between pre-existent and acquired infection | |

| |Rate of infection in offenders is unknown | |

|For this particular pt |Possibly needs wt-based regimen | |

| |Possible poor compliance and follow up. Simple and short regimen preferred | |

| |Consider potential interactions, if using illicit or other meds. | |

| |Will need baseline vaginal swabs and bloods for HBV, HCV and HIV | |

|? No prophylaxis |If patient refuses. | |

|Stat regimen |Ceftriaxone 250mg IM. Painful injection. | |

| |Plus Azithromycin 1g (or 20mg/kg) orally | |

| |Plus Metronidazole (30mg/kg up to 2g) orally | |

| |Or Tinidazole (50mg/kg up to 2g) orally | |

|Other Oral Abx |Doxycycline or erythromycin: together with ceftriaxone, if not already pregnant. | |

| |Oral Ciprofloxacin as stat. | |

| |Variable tolerance to oral Abx. | |

|Follow up |Crucial. Liaise with GP or community health service. Provide written info. | |

|Other |Consultation | |

Question 3: Outline the issues surrounding post exposure prophylaxis for HIV and viral Hepatitis in this patient.

|Expected Response |Details & Comments | |

|Expertise |Need to consult ID service | |

|HIV |Probable (understandable) biggest concern of pt | |

| |Requires full risk assessment: eg higher if anal rape | |

| |Probably not appropriate in this case, because likely low risk, HIV PEP not shown to be effective in rape victims, | |

| |and probable poor tolerance and compliance with PEP | |

|HBV |Uncertain risk of transmission | |

| |Vaccination and HBIG should be offered if assailant known HBV +ve or patient at high risk | |

|PROMPT for details |HBIG reduces risk of infection by 75% if assailant has acute HB | |

|HCV |No PEP currently available. Risk of transmission lower than for HBV, higher than HIV. | |

|Confidentiality |Pt’s existent sero-status relevant | |

|Counselling |Legal obligation with HIV | |

|Follow up PROMPT for details |3, 6 months and beyond | |

|Other | | |

Question 4: The patient asks for emergency contraception. Outline your approach to this request.

|Expected Response |Details & Comments | |

|Issues |Specific regimen, and its side effects / complications | |

| |ßHCG negative | |

| |Antiemetics | |

| |Counselling & Follow up | |

| |Confidentiality | |

| |PROMPT for indications – unprotected sex, < 72 hours, regardless of cycle, exclude pregnancy first | |

|Regimen |Candidates should explain / discuss / justify their option | |

| |Options: | |

| |Nothing | |

| |Yuzpe (oestradiol 100g and levonorgestrel 0.5mg x 2) | |

| |Levonorgestrel 0.75mg x 2 12 hours apart | |

| |IUD: not appropriate in 16yo | |

|Antiemetics |Forewarning, general advice and prophylactic metoclopramide | |

|Counselling |Complicated, with multiple issues | |

| |Enlist help: social work, GP, community services | |

|Other | | |

Comments: (if you fail the candidate, please state why) Total Mark:

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If the candidate fails the exam overall, what feedback would you suggest CIC provide for this SCE?

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SCENARIO

You are the duty consultant in an urban ED. Scanning the list of patients waiting to be seen, you note the case of a 16 year-old girl, whose triage notes are as follows:

“Requesting the morning-after pill. Some bruising on face. Patient explains that she fell yesterday. P 90, BP 110/60, Afeb.”

Question 1: You attend to the patient yourself. In confidence, she describes being sexually assaulted the previous day. Outline the key assessment issues.

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