114.The answer is b.(Hamilton et al, p 6.)Theemergency physician
(EP)approaches a problem by considering the most serious diseasecon-
sistent with the patient complaint and working to exclude it. Thinking of the
worstfirst is a reversal from the sequence of patient management in many
other specialties. Once the EP rules out the life-threatening processes, more
benign processes may be considered. This principle is particularly important
when placed in the context of the patient population seen in the ED. Most of
the patients are new to the EP; many are intoxicated or are brought to the ED
by others. This leads to an array of fragmented histories, masked physical
findings, and high emotional levels. In this setting, it is even more important
for the EP to maintain a high level of suspicion for serious diseases.
All of the conditions listed as answer choices can be responsible for the
patient’s presentation. As discussed, it is important to first rule out the life-
threatening processes. To address these processes, the patient requires a
β-hCG to rule out an ectopic pregnancy; either an ultrasound or CT scan
to evaluate for appendicitis; and a urinalysis to investigate pyelonephritis.
115.The answer is e.(Riviello, 2005.)When a sexual assault patient is
evaluated in the ED, the EP not only has the standard responsibility to care
for the patient’s immediate physical and psychological health, but he/she
must also consider how the encounter may affect the patient’s life consid-
erably once discharged from the ED. Once life-threatening injuries are
addressed, EPs are responsible for collecting physical evidence necessary
for prosecuting the assailant by conducting a sexual assault or “rape kit”
with the patient’s consent.
Most medications provided to sexually assaulted patients are provided as pro-
phylaxis against sexually transmitted infections (STIs), pregnancy, and tetanus.
Major STIs of concern are gonorrhea (ceftriaxone),Chlamydia(azithromycin or
doxycycline),syphilis, and trichomoniasis (metronidazole)because of their
relatively high incidence. The decision to provide HIV postexposure pro-
phylaxis (PEP)after sexual assault must take into account the risks and ben-
efits of treatment, the interval between exposure and treatment with
antiretrovirals, and the likelihood of exposure to HIV. The average risk of HIV
transmission per contact of unprotected receptive anal intercourse is approx-
imately 1% to 5%. For unprotected insertive anal intercourse and receptive
vaginal intercourse, the risk is approximately 0.1% to 1%. Some states man-
date offering and providing HIV postexposure prophylaxis (PEP) to all sexu-
ally assaulted patients. The risk of pregnancy following sexual assault is
approximately 5%. Emergency contraceptionis the use of hormone pills to
124 Emergency Medicine