Can you write a history and physical (H&P) for a 14‑year‑old female with a history of sexual assault who is presenting for a clinic follow‑up after treatment for a sexually transmitted infection and review of her testing results?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: September 26, 2026 • View editorial policy

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question

History and Physical Examination for 14-Year-Old Female Sexual Assault Survivor: Follow-Up Visit After STI Treatment

Chief Complaint

Follow-up visit after sexual assault with STI treatment and test result review.

History of Present Illness

This follow-up visit should occur within 1-2 weeks of initial presentation to assess injury healing, medication adherence, and emotional status 1.

Assault-Related History (if not previously documented)

  • Date and time of assault (critical for determining prophylaxis windows and testing timelines)
  • Type of penetration: vaginal, anal, oral, or contact with ejaculate on genitalia
  • Number of perpetrators and relationship to patient
  • Use of force, weapons, or substances (alcohol, drugs)
  • Any loss of consciousness or memory gaps (suggests drug-facilitated assault)

Interim History Since Initial Visit

  • Medication adherence: Completion of prophylactic antibiotics (ceftriaxone, azithromycin/doxycycline, metronidazole) 2, 1
  • Side effects from medications: Gastrointestinal symptoms, allergic reactions
  • Emergency contraception use: If applicable, timing and any adverse effects
  • New physical symptoms:
    • Vaginal discharge, odor, or bleeding
    • Dysuria or urinary frequency
    • Abdominal or pelvic pain
    • Rectal pain or bleeding (if anal penetration occurred)
    • Oral lesions or throat pain (if oral penetration occurred)
  • Injury healing: Resolution of any documented trauma
  • Sexual activity since assault: Partners, condom use (49.2% of survivors are sexually active at follow-up, with 73.3% not using condoms consistently) 3

Psychological Assessment

Responses to sexual assault vary widely, and both physical and psychological needs must be addressed 1. Screen for:

  • Sleep disturbances (commonly reported) 3
  • Appetite changes (commonly reported) 3
  • Sexual function concerns (commonly reported) 3
  • Assault-related fears 3
  • Depression symptoms: Sadness, anhedonia, hopelessness
  • Posttraumatic stress symptoms: Intrusive thoughts, avoidance, hypervigilance, nightmares
  • Suicidality: Active or passive ideation, plan, intent 4
  • Self-blame or humiliation (may prevent care-seeking) 1
  • Substance use changes

Support System

  • Caregiver/trusted adult involvement: 95% of patients who complete follow-up are accompanied by caregiver 5
  • Mental health counseling initiated: Trauma-focused cognitive behavioral therapy is effective 1
  • School attendance and functioning
  • Peer relationships

Legal/Social Services

  • Child protective services involvement (associated with 74.2% follow-up rate) 5
  • Law enforcement involvement (associated with 64.7% follow-up rate) 5
  • Forensic interview completion

Review of Systems

Constitutional

  • Fever, chills, weight changes, fatigue

Genitourinary

  • Vaginal discharge, bleeding, dysuria, frequency, urgency
  • Last menstrual period, regularity
  • Pregnancy symptoms if emergency contraception was not used or failed

Gastrointestinal

  • Abdominal pain, nausea, vomiting, diarrhea, rectal bleeding

Dermatologic

  • Rashes, lesions, genital sores

Psychiatric

  • As detailed above in psychological assessment

Past Medical History

  • Previous STI history
  • Chronic medical conditions
  • Psychiatric diagnoses
  • Previous sexual trauma or abuse

Medications

  • Current medications
  • Allergies
  • Completion status of prophylactic regimen

Immunization History

  • Hepatitis B series: Complete or needs continuation 2, 1
  • HPV series: AAP recommends initiating at age 9+ or completing series 2

Social History

  • Living situation and safety
  • School performance
  • Substance use (alcohol, marijuana, other drugs)
  • Previous consensual sexual activity (relevant for interpreting positive STI results, though legally protected information) 2

Physical Examination

General Appearance

  • Affect, eye contact, interaction with caregiver
  • Signs of distress or anxiety
  • Nutritional status

Vital Signs

  • Blood pressure, heart rate, temperature, weight

Skin

  • Examine for healing of any documented injuries
  • New rashes or lesions suggesting STI (e.g., syphilis chancre, condyloma)

Oropharynx

  • If oral penetration occurred: lesions, erythema, exudate

Abdomen

  • Tenderness, masses, organomegaly
  • Suprapubic tenderness
  • Rebound or guarding (concerning for pelvic inflammatory disease)

Genitourinary Examination

Most patients (98%) have normal general examination findings and 94.8% have normal gynecologic findings at follow-up 3. However, examine for:

  • External genitalia: Healing of documented injuries, new lesions, discharge
  • Speculum examination: Generally avoid unless clinically indicated, as it may be traumatic for adolescents and lead to future healthcare avoidance 2. If performed:
    • Cervical discharge, friability, motion tenderness
    • Vaginal discharge characteristics
  • Bimanual examination: Only if clinically indicated for pelvic pain or suspected pelvic inflammatory disease
    • Cervical motion tenderness
    • Adnexal tenderness or masses
    • Uterine size and tenderness

Rectal Examination

  • Only if anal penetration occurred and symptoms present
  • Healing of injuries, discharge, lesions

Lymph Nodes

  • Inguinal lymphadenopathy (suggests active infection)

Laboratory Testing and Results Review

Initial STI Test Results

Review results from initial visit (typically NAATs for gonorrhea, chlamydia, trichomonas):

  • If prophylaxis was given: Cultures not needed at follow-up unless requested by patient 1
  • If no prophylaxis given: Repeat testing indicated

Follow-Up Testing Schedule

CDC recommends the following timeline if initial tests were negative and assailant infection status unknown 1:

  • 2 weeks: Pregnancy test 1
  • 6 weeks: Syphilis and HIV testing 1
  • 3 months: HIV testing 1
  • 6 months: Syphilis and HIV testing 1

Current Visit Testing (typically 1-2 weeks post-assault)

  • Pregnancy test: Urine hCG 1
  • Repeat STI testing: Only if prophylaxis not given or new symptoms
  • Consider baseline syphilis/HIV: If not done initially or in high-prevalence areas

Assessment and Plan

STI Treatment Status

  • Document completion of prophylactic regimen
  • Address any positive test results with appropriate treatment
  • Discuss any treatment failures or persistent symptoms

Pregnancy Status

  • Review pregnancy test result
  • If positive: Discuss options and provide appropriate referrals
  • If negative and emergency contraception was used: Reassure

Immunizations

  • Continue hepatitis B series if not completed 2, 1
  • Continue or initiate HPV series 2

Mental Health

Trauma-focused cognitive behavioral therapy is effective for adolescent assault survivors 1.

  • Refer to sexual assault care center or mental health professional skilled in trauma care 1
  • Screen for depression, PTSD, suicidality
  • Provide crisis resources and hotline numbers
  • Encourage involvement of trusted adult/caregiver for support, though respect confidentiality preferences 1

Safety Assessment

  • Assess current safety in home and community
  • Coordinate with child protective services if ongoing concerns
  • Discuss assault prevention strategies for future

Sexual Health Counseling

  • High-risk behavior is common post-assault: Nearly half are sexually active at follow-up, often without consistent condom use 3
  • Discuss safer sex practices and condom use
  • Provide contraception counseling if desired
  • Discuss risk of re-infection with new partners

Follow-Up Plan

  • Schedule next visit based on testing timeline (6 weeks for syphilis/HIV if indicated)
  • Provide written instructions as adolescents may not recall verbal information 2
  • Coordinate with primary care provider if different from current provider 1
  • Ensure mental health follow-up is scheduled

Documentation

  • Document all findings, test results, and counseling provided
  • Note adherence to medications and follow-up recommendations
  • Document mental health referrals and patient acceptance

Common Pitfalls to Avoid

  • Assuming normal physical exam means no assault occurred: 98% have normal findings at follow-up 3
  • Performing unnecessary speculum exams: Use urine or vaginal NAATs instead to avoid re-traumatization 2
  • Neglecting mental health screening: Psychological sequelae are common and require specific intervention 1, 4
  • Failing to provide written instructions: Patients often don't recall verbal information 2
  • Not involving caregivers: 95% of patients who complete follow-up have caregiver support 5
  • Missing immunization opportunities: Complete hepatitis B and HPV series 2, 1
  • Inadequate safety assessment: Ensure ongoing safety and coordinate with protective services
  • Not addressing high-risk sexual behavior: Counsel on safer sex practices given high rates of unprotected sex post-assault 3

References

3
Research

Follow-up of sexual assault victims.

American journal of obstetrics and gynecology, 1998

Related Questions

Which laboratory tests should be ordered for a patient being evaluated for sexually transmitted infection (STI)?
What steps should be taken after exposure to a sexually transmitted infection and receiving a positive test result?
What is the appropriate management and treatment plan for a patient whose partner has a sexually transmitted infection (STI)?
What is the recommended retesting schedule for sexually transmitted infections (STIs) after completing treatment?
What is the appropriate trauma-informed psychiatric assessment and initial management for children brought by their mother who allege sexual abuse?
What medication is indicated for a patient with panic disorder who is taking desvenlafaxine and experiencing insomnia?
What causes elevated prostaglandin levels?
Is a QTc of 380 ms abnormal on an electrocardiogram?
How are low testosterone levels defined and what are the recommended treatment options?
In a 58-year-old male with pneumonia who has not improved after amoxicillin, what are the possible causes if bacterial pneumonia is still suspected?
After the last alcoholic drink, how many days does it take for platelet count to reach its nadir?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.