Domain 1, Competency 2. Evaluate population or geographically based health risk utilizing principles of epidemiology, clinical prevention, environ- mental health, and biostatistics.
Defense. Domain 1, Competency 2, was met by assessing this patient at risk of drug-facilitated sexual assault. By obtaining a comprehensive history with recall bias and hesitancy to admit the truth from the patient and her friend regarding the day’s events, such as being alone with two male peers for two hours and then found by her friend with her shirt ripped and her pants opened, a forensic evaluation for sexual assault was performed as per patient’s mother’s request for further investigation by law enforcement agency. I later counseled the parents about post- traumatic stress disorder (PTSD), adolescent home safety, and caring for their teenage daughter given the recent alcohol intoxication and possible sexual assault.
Domain 1, Competency 3. Formulate differential diagnoses and diag- nostic strategies and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy for patients who present with new conditions and those with ambigu- ous or incomplete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.
Defense. Domain 1, Competency 3, was met with the assessment of sexual assault and the examination of trauma caused by sexual activity. In this case, the patient admitted to drinking alcohol but denied use of drugs during the day; urine toxicology was ordered to assess whether other substances were used to facilitate a sexual assault and to address concerns of physiological changes caused by stimulant or depressant substances.
Domain 3, Competency 2. Evaluate gaps in health care access that compromise optimal patient outcomes, and apply current knowledge of the organization and fi nancing of health care systems to ameliorate negative impact.
Defense. Domain 3, Competency 2, was met when the unavailability of social services to provide the patient with optimum care was identifi ed and I advocated for the director of social services to be paged to ensure contact with the family the following day so that they could be referred
Chapter 8 Adolescent With Suspected Sexual Assault
95
to the community sexual assault crisis center. I also contacted the police department.
Medications
Drug: Ceftriaxone Sodium (Rocephin)
Dose range: Gonorrhea, uncomplicated: 125 mg to 250 mg intramuscu- larly (IM) as a single dose.
Sexually transmitted infectious disease; prophylaxis—victim of sexual aggression: 125 mg IM as a single dose plus metronidazole 2 g orally as a single dose plus either azithromycin 1 g orally as a single dose or doxycy- cline 100 mg orally twice a day for 7 days.
Method of administration in this case: Intramuscular.
Mechanism of action: A bactericidal antimicrobial, inhibits bacterial wall synthesis of actively dividing cells by binding to one or more penicillin bind proteins (PBPs). These proteins are associated with the bacterial cell membrane and probably serve as synthesis. The result is formation of a defective cell wall that is osmotically unstable.
Clinical use: Gonorrhea.
Side effects
Common: Diarrhea, vomiting, transient increased liver enzymes.
Serious: Disorder of gallbladder, reversible erythema multiforme, hemo- lysis, immune-mediated immune hypersensitivity reaction, Stevens-John- son syndrome, toxic epidermal necrolysis.
Drug: Metronidazole (Flagyl)
Dose range: Trichomoniasis: 2 g orally as a single dose or 250 mg orally 3 times daily or 375 mg orally twice daily for 7 days or 500 mg orally twice daily for 7 days.
Sexually transmitted infectious disease; prophylaxis—victim of sexual aggression: 2 g orally as a single dose plus ceftriaxone 125 mg IM as a single dose plus either azithromycin 1 g orally as a single dose or doxycy- cline 100 mg orally twice a day for 7 days.
Method of administration in this case: By mouth.
Mechanism of action: A nitroimidazole antibiotic. Metronidazole has a limited spectrum of activity that includes various protozoans and most Gram-negative and Gram-positive anaerobic bacteria. Metronidazole appears to selectively produce cytotoxic effects in anaerobes by a reduc- tion reaction, depriving the organism of required reduction equivalents.
Clinical uses: Trichomoniasis, bacterial vaginosis.
(continued)
Side effects
Common: Abdominal discomfort, loss of appetite, metallic taste, nausea and vomiting, Jarisch Herxheimer reaction, ataxia, dizziness, headache, peripheral neuropathy, seizure, drug interaction with alcohol.
Serious: Leukopenia, ototoxicity, thrombocytopenia.
Drug: Azithromycin (Zithromax)
Dose range: Chlamydial infection: 1 g orally as a single dose.
Sexually transmitted infectious disease; prophylaxis—victim of sexual aggression: 1 g orally as a single dose or doxycycline 100 mg orally twice a day for 7 days, plus ceftriaxone 125 mg IM as a single dose plus metron- idazole 2 g orally as a single dose.
Method of administration in this case: By mouth.
Mechanism of action: The antibacterial action of azithromycin is similar to that of erythromycin. Azithromycin inhibits messenger RNA-directed polypeptide and protein synthesis. It exerts this activity by binding at the 50 S ribosomal subunit.
Clinical uses: Gonorrhea, chlamydia, pelvic infl ammatory disease.
Side effects
Common: Abdominal pain, diarrhea, nausea, vomiting, headache.
Serious: Allergic reaction (itching or hives, swelling in face or hands, swelling or tingling in mouth or throat, chest tightness, trouble breathing), blistering, peeling, red skin rash, palpitations, dark-colored urine, pale or black stools, severe diarrhea that may contain blood, vomiting within one hour after taking the medicine, jaundice.
Drug: Levonorgestrel (Plan B)
Dose range
Before menarche: Not indicated.
After menarche: 1 tablet (0.75 mg) orally as soon as possible within 72 hours after unprotected intercourse, followed by 1 tablet (0.75 mg) orally 12 hours after the fi rst dose of 0.75-mg tablet.
Method of administration in this case: By mouth.
Mechanism of action: Oral levonorgestrel acts as an emergency contra- ceptive, principally by preventing ovulation or fertilization (by altering tubal transport of sperm and/or ova). In addition, it may inhibit implan- tation (by altering the endometrium). It is not effective once the process of implantation has begun. The major effect of low-dose levonorgestrel is the production of scanty, viscous cervical mucus, which retards sperm penetration.
(continued)
Chapter 8 Adolescent With Suspected Sexual Assault
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References
Brick, J. (2006). Standardization of alcohol calculations in research. Alcoholism: Clinical and Experimental Research, 30, 1276–1287.
Casey, C., Vellozzi, C., Mootrey, G.T., Chapman, L.E., McCauley, M., Roper, M.H., Damon, I., &
Swerdlow, D.L. (2006). Surveillance guidelines for smallpox vaccine adverse reactions.
Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, 55, 1–16.
Centers for Disease Control and Prevention (CDC), Department of Health and Human Services. (2006). Sexually transmitted diseases treatment guidelines 2006. Retrieved December 20, 2008, from http://www.cdc.gov/std/treatment/
DuMont, J., Macdonald, S., Rotbard, N., Asllani, E., Bainbridge, D., & Cohen, M. (2009). Factors associated with suspected drug-facilitated sexual assault. Canadian Medical Association Journal, 180, 513–519.
Kellog, N. (2005). The evaluation of sexual abuse in children. Pediatrics, 116, 506–512.
New York State Department of Health (NYSDOH). (2007). Protocol for the acute care of the adult patient reporting sexual assault. Retrieved December 20, 2008, from http://www .health.state.ny.us/professionals/protocols_and_guidelines/sexual_assault/
Rauchenzauner, M., Kountchev, J., Ulmer, H., Pechlaner, C., Bellmann, R., Wiedermann, C.J., &
Joannidis, M. (2005). Disturbances of electrolytes and blood chemistry in acute alcohol intoxication. Middle European Journal of Medicine, 117, 83–91.
U.S. Department of Justice, Offi ce on Violence against Women. (2004).A national protocol for sexual assault medical forensic examination adults/adolescents. Retrieved May 30, 2009, from www.ncjrs.gov/pdffi les1/ovw/206554.pdf
Clinical uses: Emergency post-coital contraception.
Side effects
Common: Weight gain, abdominal pain, altered appetite, diarrhea, nausea, vomiting, dizziness, headache, depression, breast tenderness, cyst of ovary.
Serious: Severe stomach pain, fatigue, headache, nausea, vomiting or diarrhea.
Source: MICROMEDEX Healthcare Series (2009). DRUGDEX Drug Point.
99
Adolescent Male With
Traumatic Brain Injury
This case demonstrates care I provided for a 12-year-old boy in the emergency department (ED) and in inpatient and outpatient settings. Care for this Medicaid- insured patient occurred during six encounters over a one-month period. The case narrative demonstrates my ability to meet the following Columbia Uni- versity School of Nursing Doctoral Competencies for Comprehensive Direct Patient Care:
DOMAIN 1, COMPETENCY 3
Formulate differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy for patients who present with new conditions and those with ambiguous or incomplete data, complex ill- nesses, comorbid conditions, and multiple diagnoses in all clinical settings.
PO A. Formulate a differential diagnosis for a patient who presents with new undifferentiated signs and symptoms.
9
Rachel LyonsPO B. Formulate a differential diagnosis for a patient who presents with ambiguous or incomplete data, complex illnesses, comorbid conditions, and potential multiple diagnoses.
PO C. Discuss the rationale for the differential diagnosis.
PO D. Discuss the rationale for the diagnostic evaluation with attention to sci- entifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy.
PO E. Discuss the rationale for the therapeutic intervention with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adher- ence, and effi cacy.