For optimal results, forensic material should be collected within 72 hours of the assault. Clothes, especially undergarments, need to be placed in a paper bag for drying (plastic holds humidity, which allows organisms to grow, destroying forensic evidence). The patient should be inspected for bruising, bites, and oral, genital, and anal trauma. Photographs are the best record to document injuries. Specimens should be obtained from the fingernails, mouth, vagina, pubic hair, and anus. The sexual assault kit provides materials to obtain DNA from semen, saliva, blood, fingernail scrapings, and pubic hair. A wet mount of vaginal fluids shows the presence or absence of sperm under the microscope. Cultures for STIs should be taken but are often negative (unless previously infected), because 72 hours are needed for the bacterial load to be sufficient for a culture. Blood should be drawn for baseline HIV and syphilis (Venereal Disease Research Laboratories test). All materials must be maintained in a “chain of evidence” that cannot be called into question in court.
Therapy after a rape includes prophylaxis for emergency contraception and STI and, if indicated, hepatitis immune globulin and hepatitis vaccine. A single oral dose of cefixime, 400 mg, and azithromycin, 1 g, treats Chlamydia, gonorrhea,and syphilis. An alternative regimen is a single intramuscular dose of ceftriaxone, 125 mg, with a single oral dose of azithromycin, 1 g. For prophylaxis against bacterial vaginosis and Trichomonas, a single oral dose of metronidazole, 2 g, is recommended. Repeat cultures, wet mounts, and a pregnancy test should be performed 3 weeks after the assault, followed by serology for syphilis, hepatitis, and HIV at 12 weeks. Longterm sequelae are common; patients should be offered immediate and ongoing psychological support, such as that offered by local rape crisis services.
Eating disorders are common chronic diseases in adolescents, especially in females. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), classifies these as psychiatric illnesses. The diagnosis in young adolescents (pregrowth spurt, premenstrual) may not follow the typical diagnostic criteria (Table 70-1).
The prevalence of anorexia nervosa is 1.5% in teenage girls. The female-to-male ratio is approximately 20:1, and the condition shows a familial pattern. The cause of anorexia nervosa is unknown, but it involves a complex interaction between social, environmental, psychological, and biologic events (Fig. 70-1), with risk factors having been identified (Fig. 70-2).
Screening for eating disorders is important and is best done as a part of the larger psychosocial screen for risk-taking factors (see Fig. 67-1). Although it is recommended that the adolescent be interviewed alone, he or she may minimize the problem; thus interviewing the parent(s) alone is also important. The first event usually described by an affected patient is a behavioral change in eating or exercise (i.e., food obsession, food-related ruminations, mood changes). The patient has an unrealistic body image and feels too fat, despite appearing excessively thin. Parents’ response to this situation can be anger, self-blame, focusing attention on the child, ignoring the disorder, or approving of the behavior.
The physician should be nonjudgmental, collect information, and assess the differential diagnosis. The differential diagnosis of weight loss includes gastroesophageal reflux, peptic ulcer, malignancy, chronic diarrhea, malabsorption, inflammatory bowel disease, increased energy demands, hypothalamic lesions, hyperthyroidism, diabetes mellitus, and Addison disease. Psychiatric disorders also need to be considered (e.g., drug abuse, depression, obsessive-compulsive disorders).