A 24-year-old woman presents to the emergency department 18 hours after alleged rape. She is conscious, cooperative, and medically stable. On examination, there are no visible injuries. She reports vaginal pain and mild bleeding. What is the most appropriate immediate next step in management?

Explanation

## Medical Examination Protocol in Alleged Rape Cases **Key Point:** The cornerstone of management in alleged sexual assault is a systematic, documented forensic medical examination performed by a trained examiner, regardless of the time interval since the alleged incident. ### Examination Sequence and Timing **High-Yield:** Medical examination should be performed as soon as possible but can be done up to 72 hours after the alleged assault for collection of biological evidence (semen, blood, hair). Detailed history and examination take priority over other investigations. ### Components of Forensic Medical Examination 1. **Detailed history** — circumstances, timeline, consent status, injuries, contraception use 2. **General examination** — document all injuries (photographs with consent), clothing examination 3. **Genital examination** — inspect for lacerations, bruising, bleeding; collect swabs for DNA/semen 4. **Anal examination** — if indicated by history 5. **Documentation** — use standardized proforma; all findings recorded with diagrams **Clinical Pearl:** Even in the absence of visible injuries, forensic evidence (semen, saliva, hair) may be recovered from genital swabs, anal swabs, or oral swabs. Absence of injury does NOT negate assault. ### Concurrent Management Steps | Intervention | Timing | Rationale | |---|---|---| | Forensic examination | Immediate (within 72 hrs) | Preserve biological evidence | | STI prophylaxis | After examination | Ceftriaxone 250 mg IM + Azithromycin 1 g PO | | Emergency contraception | Within 72 hrs | Levonorgestrel 1.5 mg or Mifepristone 10 mg | | Tetanus prophylaxis | If indicated | For open wounds | | Psychological support | Immediate & ongoing | Counselling, support groups | | Police notification | With patient consent | Mandatory reporting in many jurisdictions | **Mnemonic: SAFE Protocol** — **S**teps of examination, **A**ssessment of injuries, **F**orensic evidence collection, **E**motional support and safety planning. ### Legal Framework (IPC Sections) - **Section 375 IPC** — Definition of rape (penetration without consent) - **Section 376 IPC** — Punishment for rape (7 years to life imprisonment) - **Section 376A IPC** — Causing death or vegetative state by rape (life imprisonment or death) - **Section 376C IPC** — Sexual intercourse by person in authority (5 years) - **Section 376D IPC** — Gang rape (minimum 20 years) **Key Point:** Medical examination is a legal requirement and forms the basis of forensic evidence in court proceedings. Proper documentation is critical for prosecution. ### Why Immediate Examination is Essential 1. Biological evidence degrades over time 2. Injuries may fade within days 3. Patient's psychological state is better documented early 4. Chain of custody is maintained 5. Medicolegal credibility is established **Warning:** Even 18 hours post-assault, forensic evidence may still be recoverable. Do NOT delay examination.