A 19-year-old woman is brought to the hospital by her mother 6 hours after alleged rape by an acquaintance. During the forensic examination, the doctor finds no genital injuries but recovers semen from the vaginal swab. The patient is medically stable and denies any systemic injuries. What is the most appropriate next step?

Explanation

## Management After Forensic Evidence Collection in Rape Cases **Key Point:** The presence of biological evidence (semen) is HIGHLY significant and constitutes strong forensic proof of sexual contact, regardless of the presence or absence of genital injuries. Medical management must proceed with full prophylaxis and support. ### Significance of Forensic Evidence Without Visible Injury **High-Yield:** Absence of genital injuries does NOT negate sexual assault. Many cases of rape occur without physical trauma, especially when: - The victim is in shock or does not resist - The perpetrator uses threats or coercion - Lubrication or prior sexual activity reduces friction - The assault is brief or non-violent **Clinical Pearl:** Semen recovered from genital swabs is definitive evidence of penile-vaginal contact and is admissible in court. DNA analysis can identify the perpetrator with high certainty. ### Post-Examination Management Protocol ```mermaid flowchart TD A[Forensic examination complete]:::outcome --> B{Evidence collected?}:::decision B -->|Yes| C[Preserve chain of custody]:::action C --> D[Initiate prophylaxis]:::action D --> E[STI prophylaxis]:::action D --> F[Emergency contraception]:::action D --> G[Tetanus if needed]:::action E --> H[Psychological support & counselling]:::action F --> H G --> H H --> I[File medicolegal report]:::action I --> J[Notify police with consent]:::action J --> K[Follow-up at 6 weeks & 3 months]:::outcome ``` ### Pharmacological Interventions | Intervention | Regimen | Timing | Rationale | |---|---|---|---| | **STI Prophylaxis** | Ceftriaxone 250 mg IM + Azithromycin 1 g PO | Immediately after exam | Covers gonorrhoea, chlamydia, mycoplasma | | **Emergency Contraception** | Levonorgestrel 1.5 mg PO single dose OR Mifepristone 10 mg PO | Within 72 hrs (earlier = better) | Prevents pregnancy; >90% effective if given early | | **Tetanus** | TDapt or Td | If indicated by wound status | For any open lacerations | | **Hepatitis B** | HBIG + HBV vaccine series | If high-risk exposure | Prevents HBV transmission | | **HIV PEP** | TDF/FTC + Raltegravir or Efavirenz | Within 72 hrs (ideally <2 hrs) | Reduces HIV transmission risk by ~81% | **Mnemonic: STEP Protocol** — **S**TI prophylaxis, **T**etanus, **E**mergency contraception, **P**sychological support. ### Medicolegal Documentation **Key Point:** A detailed medicolegal report must be filed, documenting: 1. History of the alleged assault (in the victim's own words) 2. All examination findings (injuries, absence of injuries) 3. Forensic evidence collected (swabs, clothing, hair) 4. Photographs (with consent) 5. Diagrams of injuries 6. Opinion on consistency with alleged assault 7. Chain of custody details **High-Yield:** The medicolegal report is a legal document and may be used as evidence in court. Accuracy, objectivity, and completeness are essential. ### Follow-Up Schedule 1. **At 6 weeks** — Repeat STI testing (window period for some infections) 2. **At 3 months** — Repeat HIV testing (if PEP was given) 3. **Ongoing** — Psychological counselling and support **Clinical Pearl:** Many rape survivors experience post-traumatic stress disorder (PTSD), depression, and anxiety. Referral to a mental health professional is as important as medical prophylaxis.