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TRAUMATISED/ABUSED PatientRecognize the traumatised/abused patient needing urgent attention• Injuries need attention 38• Immediate risk of being harmed and in need of shelter• At risk of harm to self 49• Recent rape/sexual assault:--Arrange doctor assessment ideally at a designated facility for management of rape and sexual assault (same day if patient wishes to lay a charge).--All documentation and patient’s notes must be correctly completed and labelled. Record in a register and keep locked away all forensic specimens.--Aim to prevent HIV, STIs and pregnancy as soon as possible after the abuse:Prevent HIV• If status unknown, test for HIV 60.• If HIV negative or unknown, startpost-exposure prophylaxis for 1 monthwithin 72 hours of rape: AZT 300mg 12hourly and 3TC 150mg 12 hourly. Addlopinavir/ritonavir 400/100mg 12 hourlyif high risk rape: anal penetration,multiple perpetrators, perpetratorknown with HIV, or obvious genitaltrauma.Prevent STIs• If asymptomatic give cefixime400mg orally single dose anddoxycycline 100mg 12 hourly for7 days and metronidazole 2gorally single dose.• If symptomatic, treat symptoms23.• Advise patient to use condomswith regular partner for 3months.Prevent syphilis• Offer RPR:--If RPR negative,repeat after 1month.--If RPR positive28.• Advise patient touse condoms withregular partner for 3months.Prevent pregnancy (if not on contraceptiveand of child-bearing age):• Within 5 days of rape: give as soonas possible ideally within 24 hourslevonorgestrel 0.75mg 2 tablets once ornorgestrel/ethinyl oestradiol 0.5/0.05mg 2tablets and repeat 12 hours later 91.• Within 5 days: intrauterine device can beinserted 91.• After 5 days: check pregnancy test 6–8weeks after last period. If pregnant 93.Also assess and support the patient needing urgent attention as below.Approach to the traumatized/abused patientListen and support see preface• Interview the patient in a private room, supported by a trusted friend/relative if the patient wishes.• Clearly record the patient’s story in his/her own words. Include the nature of the assault and the identity of the perpetrator.• Help the patient to identify strengths and support structures. Do not give up if the patient fails to follow your advice.• Offer to see the patient again. A supportive relationship with the same health practitioner helps to contain frequent visits for multiple problems.Screen for mental problem• If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 81.• Ask ‘Are you stressed?’ If yes 52.• If > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuses illicit or prescription drugs consider substance abuse 83.Exclude pregnancy and STIs• Check for pregnancy. If pregnant 93.• If status unknown, test for HIV 60. The HIV patient needs routine HIV care 61.• Ask about symptoms of sexually transmitted infections. If present 23.Refer to available supportive resource• Refer to available trauma counselor, psychiatric nurse, psychologist, social worker, helpline back page.• Encourage patient to file a J88 form and to report case to the police. Respect the patient’s wishes if s/he declines to do so.• Encourage patient to apply for protection order at local magistrate’s court. Refer to police Victim Empowerment office, family violence NGOs for assistance.53