A patient presenting to primary care 17 days after a planned 5‑month follow‑up: what immediate assessment and laboratory studies are indicated?

Follow-Up Assessment 17 Days After Sexual Assault

Schedule an in-person visit within 1–2 weeks (which this patient is appropriately doing at 17 days) to assess injury healing, medication adherence, mental health status, and perform repeat STI testing if prophylaxis was not given or if symptoms have developed. 1, 2

Required Laboratory Testing at This Visit

STI Testing

• Repeat nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia from all sites of penetration (pharynx, rectum, vagina, urethra) if empiric prophylaxis was not given at the initial visit or if the patient has developed any symptoms. 1
• Do not repeat STI testing at this visit if the patient received and completed empiric prophylaxis and remains asymptomatic—the next STI testing should occur at 2 weeks if indicated. 2

Pregnancy Testing

• Perform a urine pregnancy test at this 2-week follow-up visit, regardless of whether emergency contraception was provided at the initial visit. 1

Baseline Serology Follow-Up

• No repeat HIV or syphilis testing is required at this visit—these should be repeated at 6 weeks, 3 months, and 6 months if initial results were negative. 1, 2

Clinical Assessment Required

Physical Examination

• Examine all documented injuries from the initial visit to assess healing progression, looking specifically for signs of infection, delayed healing, or complications. 1, 2
• Perform a focused genital examination only if the patient reports new symptoms such as discharge, pain, or bleeding—do not routinely repeat a full forensic-type examination. 2

Medication Adherence Review

• Verify completion of all prophylactic antibiotics (ceftriaxone, azithromycin, metronidazole) and document any side effects or reasons for non-adherence. 1, 2
• If HIV post-exposure prophylaxis (PEP) was initiated, assess adherence and side effects—PEP requires 28 days of treatment and close monitoring. 1, 2

Vaccination Status

• Administer the second dose of hepatitis B vaccine if the first dose was given at the initial visit (schedule: 0,1–2 months, 4–6 months). 1
• Administer the second dose of HPV vaccine if the first dose was given and the patient is eligible (females 9–26 years, males 9–21 years; schedule: 0,1–2 months, 6 months). 1

Mental Health Assessment

Mandatory Screening

• Screen for suicidal ideation, self-harm behaviors, and homicidal ideation using direct questioning—sexual assault survivors have significantly elevated rates of depression and self-harm. 3, 2
• If any suicidal or homicidal ideation is present, refer urgently to an experienced mental health professional the same day—this cannot be delayed. 3

Trauma-Focused Therapy Initiation

• Initiate or verify initiation of trauma-focused cognitive behavioral therapy (TF-CBT) immediately if not already started—this is the first-line, evidence-based treatment with large effect size reductions in PTSD symptoms. 3, 2
• Do not delay trauma-focused therapy with a prolonged "stabilization phase"—current evidence demonstrates that direct trauma-focused treatment is safe and effective immediately, with no increased risk of symptom worsening. 3

Assessment of Acute Symptoms

• Evaluate for PTSD symptoms including intrusive thoughts, avoidance behaviors, hyperarousal, and negative mood changes using standardized screening tools. 2
• Assess sleep disturbance, appetite changes, and ability to function in daily activities (school, work, relationships). 2

Documentation Requirements

• Document the patient's current symptom status including physical complaints, psychological symptoms, and any new concerns that have emerged since the initial visit. 2
• Record medication adherence and any barriers to completing prophylaxis or attending mental health appointments. 2
• Update the medical record with all laboratory results and ensure they are reviewed with the patient. 2

Schedule Future Follow-Up

• Schedule the next follow-up at 6 weeks for repeat HIV and syphilis serology, and to assess ongoing mental health needs. 1, 2
• Ensure the patient has scheduled or attended at least one trauma-focused therapy session before leaving this visit—provide specific referrals if not yet arranged. 3, 2
• Schedule 3-month and 6-month follow-up visits for completion of the vaccination series and final HIV/syphilis serology testing. 1, 2

Critical Pitfalls to Avoid

• Do not skip pregnancy testing even if emergency contraception was given—it can fail, and early detection of pregnancy is essential for patient autonomy and decision-making. 1
• Do not delay mental health referral if the patient reports any psychological distress—waiting for symptoms to worsen before intervening increases the risk of chronic PTSD. 3, 2
• Do not repeat full STI testing if the patient completed prophylaxis and is asymptomatic—this wastes resources and the next testing window is at 2 weeks or if symptoms develop. 1, 2
• Do not assume the patient is "doing fine" without direct screening for suicidal ideation—many patients will not volunteer this information unless specifically asked. 3, 2