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A comprehensive description of treatment interventions and techniques specific to arrhythmia overview cheap isoptin 240mg without prescription each of the targeted behavioral/symptoms c pulse pressure youtube buy isoptin 40 mg otc. Establishment of treatment goals and objective measures of progress for each intervention specified (including baseline and targeted goals) d pulse pressure greater than 40 purchase isoptin 120mg with visa. Specific behavioral goals that blood pressure chart uk pdf generic isoptin 240 mg with mastercard, when reached, will indicate the patient is adequately participating in home, school, or community activities and/or is no longer presently a safety risk to self or others 5. Their behaviors and/or symptoms can be adequately addressed through alternative methods. As noted in the 2014 Agency for Healthcare Research and Quality update on A Review of Research of Therapies for Children with Autism Spectrum Disorder, early intervention programs. These services can include direct services to member/identified patient and/or parents by program manager/lead behavioral therapist and/or therapy assistants/behavioral technicians/paraprofessionals, supervision, and the development of a six-month progress report. Progress towards parent goals (how parents have been active participants in the treatment, what percentage of parent goals have been passed, and progress towards transferring interventions with the patient to the parents) c. New goals should be geared towards progress or transition to less intensive interventions. A brief description of what was done during the past six months to coordinate treatment with school and/or health care providers. More than one program manager/lead behavioral therapist for a member/identified patient at any one time. Assisting the member/identified patient with academic work or functioning as a tutor, educational or other aide for the member/identified patient in school © 2010 Kaiser Permanente. Be a licensed health provider under Title 18, Revised Code of Washington, including but not limited to: speech therapist, occupational therapist, psychologist, pediatrician, neurologist, psychiatrist, mental health counselor, social worker; and 2. Patients may experience rest pain, ulceration, claudication, hospitalizations, and even amputation of limb. These include age fi 70 years, age 50 to 69 years with a history of diabetes or smoking, age 40 to 49 with diabetes and at least one other risk factor for atherosclerosis, leg symptoms indicative of claudication with exertion or ischemic pain at rest, abnormal lower extremity pulse examination, known atherosclerosis at other sites (coronary, carotid, renal artery disease) (Hirsch et al. These encompass devices using oscillometric technology and plethysmographic-based technology. It uses air plethysmography technology to perform these assessments (Millen et al. The Dopplex ability is intended for wound care for arterial disease before deciding on compression bandaging. The use of Ankle-Brachial Index device using plethysmographic method for the diagnosis of peripheral artery disease does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 8/25/20 32 these criteria do not imply or guarantee approval. If requesting this service, please send the following documentation to support medical necessity: • Last 6 months of clinical notes from requesting provider &/or specialist the following information was used in the development of this document and is provided as background only. It is a 2-4mm thick hyaline cartilage that provides smooth low friction movement and shock absorption. Unlike most tissues, articular cartilage does not have blood vessels, nerves, or lymphatics. Back to Top Date Sent: 8/25/20 34 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History joint function and may lead to the development and progression of osteoarthritis. The damaged cartilage has very limited capacity for self-repair due to its avascular and hypocellular nature. Surgery has thus been the standard approach for repairing articular cartilage damage. Reparative, which includes marrow stimulation such as microfracture; drilling; and abrasion arthroplasty, and 2. Currently, marrow stimulation through microfracture is the standard first-line surgical treatment for articular cartilage lesions of the knee. It is a single-stage arthroscopic procedure that involves penetrating the subchondral bone plate after removing the damaged hyaline cartilage. The technique is minimally invasive, technically simple, and is associated with low morbidity. However, the repair is composed of fibrocartilaginous tissue, which is mechanically inferior to the native hyaline cartilage; it has less ability to withstand shock and shearing forces leading to deterioration in function over time. In addition, the bone marrow stem cells and growth factors are released into the joint rather than being contained in the site of the defect. Some researchers suggest that microfracture is more effective in reducing pain and improving joiny function when performed for new injuries, small focal injuries, and in younger individuals with lower body mass index (Crawford 2012, Negrin 2013, Lee 2014, Mundi 2015). It is a surgical technique that uses osteochondral grafts taken from the lighter-load bearing areas of the patient’s own joint to fill the focal defects. There is a concern however, with the donor site morbidity, and thus the technique may not recommend for lesions larger than 400mm2 (Li 2015, Mundi 2015). The specimen of live articular cartilage is sent to a cell expansion laboratory for chondrocyte culture. The cultured chondrocytes are then implanted into the cartilage defect in an open arthrotomy procedure. The technique has variable success rate and may be associated with periosteal hypertrophy and overgrowth that would require additional surgeries (Crawford 2012, Niemeyer 2014, Mundi 2015). Back to Top Date Sent: 8/25/20 35 these criteria do not imply or guarantee approval. The only data available are from case series report that have compromised validity and are not considered to provide high quality data. Peterson and colleagues are involved with a prospective randomized trial of autologous chondrocyte transplantation compared to periosteum alone or subchondral drilling for the treatment of primary chondral lesions of the femoral condyle. Eleven articles were not directly relevant, did not include clinical outcomes or were review articles; three articles presented empirical data on clinical outcomes. An evidence table was created for the two-case series reports with the largest number of patients: Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl, A. Neither provided strong evidence that autologous chondrocyte implantation is superior to an alternate procedure for repairing osteochondral defects in the knee. The Horas study had inadequate randomization and several additional threats to validity. They found worse post-operative knee instability in the autologous chondrocyte transplantation group compared to a group receiving autologous osteochondral cylinder transplantation and no significant differences between groups on the two other primary measures. The use of Autologous Chondrocyte (Carticel) Implantation for Treatment of Defects in Articular Cartilage of the Knee does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Articles: the Medline search yielded 42 articles, many of which were on technical aspects of the procedure or on related technologies. Back to Top Date Sent: 8/25/20 36 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History the use of Autologous Chondrocyte (Carticel) Implantation for Treatment of Defects in Articular Cartilage of the Knee does not meet the Kaiser Permanente Medical Technology Assessment Criteria. In addition, none of the trials was blinded and pain and function measures mainly relied on subjective evaluation, which may bias the results. The majority of the studies were underpowered to detect statistical differences, and a lack of significant differences between procedures does not necessarily © 1998 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 8/25/20 37 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History indicate that they are equivalent or have similar effects. Combining the studies into meta-analyses increases the power, but the significant heterogeneity between the published studies on the treatment of chondral lesions in the knee precluded pooling the results of the individual studies in many cases, and/or performing subgroup analyses to determine the optimal procedure to the patient according to the lesion size, type of activity, comorbidity, and other characteristics. The meta-analysis had valid methodology and analysis, but the included studies had their limitations, and were significantly heterogeneous. The authors could not pool the results of the comparative studies into a meta-analysis due to the significant heterogeneity between the studies. The authors noted however, that the variation in techniques and modifications used for repairing chondral lesions of the knee, together with the different outcomes and measures used, and lack of long-term follow up make it hard to compare techniques and /or determine the optimal procedure for the different patient groups. The meta-analysis had some disadvantages which may limit generalization of its results. The study had 90% power to detect a significant difference in the success rate between the two techniques. Subgroup analyses showed no significant differences by age (at 35 years cutoff), and that females had more treatment failures irrespective of the procedure they underwent. There was a 23% failure rate (need for a reoperation due to lack of healing) in each of the treatment groups at 5 years compared to only 2.

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Persecutory delusions occur in many different conditions: in schizophrenia blood pressure normal reading discount 240mg isoptin mastercard, in affective psychoses of manic and depressive type and in organic states arrhythmia gif buy isoptin 120mg on-line, both acute and chronic hypertension united states 240mg isoptin otc. The affect associated with the belief of persecution may vary from an inappropriate indifference and apathy in schizophrenia to blood pressure and heart rate order isoptin no prescription stark terror, as commonly seen in delirium tremens. Manic patients with persecutory delusions show gross overactivity and fight of ideas in attempting to express and deal with their beliefs. In depression, the persecutory delusions take on the characteristic colouring of the dominant mood state. Persecutory overvalued ideas are a prominent facet of the litigious type of paranoid personality disorder. The feeling of jealousy, coupled with a sense that the loved object ‘belongs to me’ and, therefore, ‘I belong to the other’, is part of normal human experience; it is of social value in marital relationships for preserving the family. Enoch and Trethowan (1979) have considered it important to distinguish psychotic jealousy from other types, and this is dependent on the demonstration of a delusion of infdelity. It is sometimes diffcult to distinguish understandable jealousy from that which is delusional. Mullen (1997) classifed morbid jealousy with disorders of passion, in which there is an overwhelming sense of entitlement and a conviction that others are abrogating the subject’s rights: ‘The morbidly jealous believe that they are the victims of an infdelity that has deprived them of the fealty which is their due and they are driven to expose this disloyalty, reassert their control and punish the transgression’. The other two categories are the querulant, who are indignant at infringements of rights, and the erotomanic, who are driven to assert their rights of love. Delusion of infdelity, that is, when the subject unreasonably believes him or herself to be the victim of their partner’s unfaithfulness, may occur without other psychotic symptoms. A patient was very concerned that his wife was being unfaithful with numerous people, including his boss, her general practitioner and others. Four years later, despite various treatments, his belief was unchanged, but he said, ‘I don’t blame her now. Delusions of jealousy are common with alcohol abuse; for instance, Shrestha et al. As jealousy appeared to be justifed in some cases, morbid jealousy was considered to be present in 27 per cent of men and 15 per cent of women. Delusional jealousy, often associated with impotence, also occurs in some organic states, for example the punch drunk syndrome of boxers following multiple contrecoup contusion. Quite frequently, the spouse, wearied by continued accusations of infdelity, does form another sexual involvement, which may result in an acute exacerbation in the mental state of the patient and further marital confict. The sexual content of the delusion is obvious; however, Enoch (1991) regards the nature of the relationship between the two partners as the key aspect of the condition. The deluded person is very attached to, and often emotionally utterly dependent on, the other; he may have a misplaced sense of owning her completely. The victim is often much more sexually attractive than the deluded partner, for instance a young wife or a sociable and popular husband. The deluded person may have been promiscuous in the past and therefore resignedly expects his spouse to show similar behaviour. He may have homosexual fantasies directed towards the men with whom he claims his wife is consorting. Morbid jealousy arises with the belief that there is a threat to the exclusive possession of his wife, but this is just as likely to occur from conficts inside himself, his own inability to love or his sexual interest directed towards someone else as from changing circumstances in his environment or his wife’s behaviour. Husbands or wives may show sexual jealousy, as may cohabitees and homosexual couples. Crimes of violence are notoriously associated with morbid jealousy; violence is more often vented on the partner than on the supposed rival, most often by men on women. Morbid jealousy makes a major contribution to the frequency of wife battering and is one of the commonest motivations for homicide (Mullen, 1990). Both these latter conditions exist initially in the opinion of an external commentator – the doctor. Approximately twice as many schizophrenic patients had sexual preoccupations in the midtwentieth century as compared with in the mid-nineteenth century (Klaf and Hamilton, 1961). Erotomania was described by Sir Alexander Morrison (1848) as being: characterized by delusions the patient’s love is of the sentimental kind, he is wholly occupied by the object of his adoration, whom, if he approaches, it is with respect the fxed and permanent delusions attending erotomania sometimes prompt those labouring under it to destroy themselves or others, for although in general tranquil and peaceful, the patient sometimes becomes irritable, passionate and jealous. Erotomania is commoner in women than in men, and a variety has been called ‘old maids’ insanity’ by Hart (1921), in which persecutory delusions often develop. Trethowan (1967) demonstrated the social characteristics of erotomania, relating the patient’s previous diffculties in parental relationships to the present erotomania. A variation of erotomania was described by, and retains the name of, de Clerambault (1942). Typically, a woman believes a man, who is older and of higher social status than she, is in love with her. The victim has usually done nothing to deserve her attention and may be quite unaware of her existence; sometimes he is a well-known public fgure quite remote from the patient. She believed that he was the father of her child (although at another time she agreed that there had been no sexual relationship with her employer). She also believed that he was sending her money, and she would write letters thanking him for his generosity and affrming her gratitude for the evidence of his love (Sims and White, 1973). In a series of 16 erotomanic cases, Mullen and Pathe (1994) tried to distinguish between those cases in which there is a morbid belief in being loved and those with morbid infatuation. They found that in most cases both notions were described: a mixture of being loved and loving in return. These syndromes include Capgras’ syndrome (Capgras and Reboul-Lachaux, 1923), Fregoli’s syndrome (Courbon and Fail, 1927), the syndrome of intermetamorphosis (Courbon and Tusques, 1932) and the syndrome of subjective doubles (Christodoulou, 1978). Capgras’ syndrome is regarded by Enoch and Trethowan (1979) as ‘a rare, colourful syndrome in which the person believes that a person, usually closely related to him, has been replaced by an exact double’. It is a specifc delusional misidentifcation of a person with whom the subject usually has close emotional ties and towards whom there is a feeling of ambivalence at the time of onset. The belief, in Capgras’ syndrome, has the full characteristics of delusion (Enoch and Trethowan, 1979). The basic concept of this syndrome is prominent in all cultures, hence the delusion is universal (Christodoulou, 1991). Like other delusions, delusion describes the form; the content is culture-dependent. A recent patient believed his mother had been replaced by an impostor after falling through a time warp to a parallel universe, and this explained the horrible things that had happened in the past three weeks. Fregoli’s syndrome is the delusional misidentifcation of an unfamiliar person as a familiar one, even though there is no physical resemblance. The syndrome of intermetamorphosis is the delusional belief that others undergo radical changes in physical and psychological identity, culminating in a different person altogether. The syndrome of subjective doubles is the delusional belief in the existence of physical duplicates of the self, and these duplicates are usually thought to have different psychological identities (see Moselhy and Oyebode, 1997, for review). In a series of cases reviewed by Berson (1983), 55 per cent (70 patients) were unquestionably diagnosed as suffering from schizophrenia, and a further eight patients (totalling 61 per cent) were probably suffering from schizophrenia; 13 per cent were suffering from bipolar mood disorder and 24 per cent were considered to have an organic diagnosis. Of 133 patients, 57 per cent were female; the age range was from 12 to 78, with a mean of 42. Majority opinion would not favour denoting this as a separate disease but rather as a symptom that colours the clinical state and dominates the symptomatology. The four different varieties of delusional misidentifcation have in common psychopathologically the form of a delusion. Capgras’ syndrome, when it occurs in schizophrenia, is based on a delusional percept (Sims, 1986). Sometimes patients will say, ‘I know that it is not my mother because she would never stand like that’ or ‘this person moves too slowly to be my father’. The ambivalence towards the object of misidentifcation may be expressed in the history, with a clear account of both negative emotions, such as hostility, fear or contempt, and affection and dependence. On those few occasions when an object, rather than a person, is wrongly identifed, that object has important emotional connotations for the patient, for example home or a letter from a relative. The subjects of misidentifcation in Berson’s (1983) review of 133 patients comprised 60 spouses and two lovers; on 29 occasions, a child or children; 40 parents; 24 siblings; 13 therapists; four grandparents; three in-laws; two neighbours; two domestics; and one each of fance, cousin, stepson, employer and priest. On eight occasions, the self was misidentifed either solely or with other evidence of the syndrome; on two occasions, animals, and eight times inanimate objects were misidentifed. Thus, in 31 per cent of occasions, the delusional misidentifcation refers to a marital partner, and in 46 percent to a frst-degree relative; in only four per cent was the misidentifcation of the patient himor herself. There is growing evidence that delusional misidentifcation syndromes are associated with organic disorders, including dementia, acquired brain injury, epilepsy and cerebrovascular accidents in 25 to 40 per cent of cases, and neuroimaging studies reveal association with right hemisphere abnormalities, particularly in the frontal and temporal regions (Edelstyn et al. Furthermore, neuropsychological investigations have consistently shown impairments of face processing in delusional misidentifcation syndromes (Edelstyn et al.

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This is supplied with forms on which the applicant’s score is recorded and which indicate the type of colour vision defect blood pressure urination isoptin 120 mg generic. A more complex test is the Farnsworth-Munsell 100 hue test which consists of four trays containing a total of 85 removable reference caps blood pressure 13080 discount isoptin generic. The colour caps have incremental hue variation on one side and are numbered on the reverse blood pressure under stress discount isoptin express. Colour vision anomalies are detected by the ability of the subject to arrhythmia kamaliya download buy isoptin with american express place the colour caps in hue order. Several different lanterns have been used by Contracting States, but there is no consensus on any particular one as a universal standard. Some of the lanterns which have been used and are still used include the Spectrolux lantern, the Beyne lantern, the Eldridge-Green lantern, the Farnsworth lantern, the Giles-Archer lantern, the Holmes-Wright lantern, the Royal Canadian Air Force lantern, and the Optec 900 lantern. These lanterns vary in their complexity and price, but none is clearly to be preferred and several are no longer available for purchase. Vision testing software programmes have been developed for use on personal computers and on more sophisticated equipment, and such programmes are designed to test colour vision and other visual functions. It is likely that in the next few years some of the traditional tests of colour vision will be replaced with more modern equipment. In the Nagel anomaloscope one half of the screen can be adjusted by varying the proportions of red and green light so as to match the other yellow half of the screen. Dichromats accept all red-green mixtures if the yellow brightness is properly adjusted. Anomalous trichromats accept only abnormal mixtures; the deuteranomalous use more green and the protanomalous more red. Anomaloscopes give both qualitative and quantitative assessment of the colour vision deficiency. These instruments are difficult to use, expensive, and not generally available but may be found in major clinics and research centres. The red-green types are inherited as a sex-linked recessive trait which is typically manifest in men and transmitted by women. There is less information available about tritanopia which may be polygenetic and inherited as an irregular dominant trait. Despite all the work undertaken concerning colour vision, a challenge remains to determine exactly where the cut-off between “safe” and “unsafe” should be with respect to an initial applicant who chooses aviation as his career or hobby. The more important causes include: a) Tapeto-retinal degenerations and pigmentary retinopathies; b) Chorioretinitis from any cause including macular lesions; c) Optic neuropathy from any cause including advanced glaucoma; d) Drug toxicity affecting the macula or the optic nerve. Sildenafil (Viagra) is a drug which is widely used in the treatment of erectile dysfunction in males that has been shown to cause light sensitivity and bluish colour tinge of viewed objects in 3 to 11 per cent of users. These effects may last up to five hours or longer and could be dangerous in situations where correct colour identification of blue or green light is required. Some Contracting States test all flight crew and air traffic controllers on a regular basis and test each eye separately using a method which screens for yellow-blue defects in addition to the more common red-green defects. This allows detection of the uncommon but important acquired colour vision defects. Studies of colour perception in the aviation environment have so far been limited. Further research in this area is required to determine precisely the importance of colour perception and what defects can be allowed without affecting safety. There shall be no active pathological condition, acute or chronic, nor any sequelae of surgery or trauma of the eyes or adnexa likely to reduce proper visual function to an extent that would interfere with the safe exercise of the applicant’s licence and rating privileges. In many cases the problems will be treatable, allowing the applicant to reapply after successful therapy. Cornea a) History of recurrent keratitis, corneal ulcers, corneal scars or vascularization which interferes with vision. Uveal tract a) History of anterior uveitis except on a single occasion and without sequelae. Any history of posterior uveitis (choroiditis) or signs of chorioretinal scars except minor scars not affecting central or peripheral vision when tested by ordinary clinical methods. Retina and optic nerve a) Any of the tapeto-retinal degenerations of the retina including pigmentary retinopathies. Lens a) Lens opacities (cataract) affecting visual acuity, visual field or causing glare. Above normal intraocular pressure not accompanied by demonstrable optic nerve damage does occur (ocular hypertension). Other cases occur in which typical glaucomatous damage to the optic nerve with associated visual field loss — the hallmark of glaucoma — is seen in spite of intraocular pressure measurements generally considered to be normal (normal pressure or low pressure glaucoma). The most accurate method is by applanation or flattening of the cornea utilizing a contact tonometer mounted on a slit-lamp. Such instruments are expensive and not usually available to non-specialist physicians. Hand-held instruments such as the Perkins tonometer are satisfactory, less expensive and may be practical in situations where fairly large numbers of screening examinations are done. Indentation instruments such as the Schiotz tonometer are widely available and reasonably accurate if they are properly maintained and correctly used. After ten to fifteen seconds to allow the anaesthetic to work, the examiner uses thumb and forefinger or middle finger to hold the eyelids open without pressing on the eye. The applicant is instructed to look straight upwards (looking at his own finger held up in front of the eyes is helpful) while the tonometer is lowered gently onto the centre of the cornea, care being taken to keep the instrument vertical. Gentle fluctuation of the tonometer needle is a good indication that the instrument is correctly positioned and is transmitting the normal ocular pulsations. Standard tables (Friedenwald tables) are used to determine the intraocular pressure. For a given scale reading the ocular pressure will depend on which tonometer weight was used. If the glaucoma is secondary to some underlying disease such as anterior uveitis, the treatment will be that of the underlying disease. It can be treated with laser or conventional surgery but in most parts of the world topical drug therapy is the initial treatment of choice. Laser therapy or filtering surgery is used for patients whose glaucoma cannot be satisfactorily controlled with medications. The main groups of pharmaca used for treating primary open angle glaucoma are the following: a) Epinephrine derivatives. They are useful in flight crew because they produce no significant blurring of vision but can cause local irritation of the eyes and also systemic effects such as cardiac arrhythmia. They induce miosis and accommodative blurring of vision, especially in young individuals and for this reason are generally not allowed in flight crew. They are potent, but may have numerous systemic side effects including bradycardia, central nervous system effects, and aggravation of asthma. Examples of topical carbonic anhydrase inhibitors include dorzolamide and brinzolamide. These drugs work by reducing aqueous humour production and by increasing uveoscleral outflow. These are useful because they simplify the treatment regimen and lead to better patient compliance. Such mixtures have the side effects of their components, and those containing pilocarpine will not be suitable for most flight crew. Examples of available combinations are dipivefrin/levobunolol, pilocarpine/timolol, and dorzolamide/ timolol. Fitness for flying will depend on what medications are required to control the disease and what side effects, if any, these produce. New generations of aircraft and navigation systems together with improved instrumentation and new ways to manage increasingly crowded airspace bring with them challenges to flight crew, ground support staff, air traffic controllers and those charged with supporting the health of aviation workers and improving the comfort and safety of their workplace. Improved surgical techniques and better medical management of many disorders enable individuals who might have had to stop working in the aviation environment to continue safely and effectively. This is most likely to occur in the sections dealing with refractive surgery and with glaucoma medications. Updating will be required in a few years to keep pace with further developments in medical science and to make new adjustments to the changing occupational demands of flight crew and air traffic controllers, the paramount concern remaining the safety of aviation.

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Some rapists believe they are entitled to arrhythmia heart buy isoptin 240mg online their victim arteria subclavia buy cheap isoptin 240 mg line, as in acquaintance rape or father–daughter incest (116) blood pressure medication names starting with c purchase 120mg isoptin fast delivery. A consistent finding among all types of rapists is a lack of empathy for the survivor blood pressure potassium order isoptin 120mg overnight delivery. Even when sexual assaults are reported (only 16% of rapes are reported to the police), few rapists are arrested, and even fewer are brought to trial and convicted. Successful prosecution of rapists is often dependent on the extent of the survivor’s injuries and the completion of a detailed forensic examination (147). Many women do not report the assault to the police because they are concerned about their name being disclosed by the news media, they fear retaliation from the perpetrator, are afraid they will not be believed, or do not trust the judicial process (148). Assault is more likely to be repeated if survivors in abusive relationships do not seek medical care, report the incident to police, or seek an order of protection (116). Women are more likely to immediately seek treatment after sexual assault if weapons were involved, serious physical injury occurred, or physical coercion or confinement was used in the assault (149). Many rape survivors do not inform their physicians about the assault and may never volunteer information about the assault unless they are directly asked. When obtaining a medical history, physicians should routinely ask, “ Has anyone ever forced you to have sexual relationsfi The initial reactions to sexual assault may be shock, numbness, withdrawal, and possibly denial. Despite their recent trauma, women presenting for medical care may appear calm and detached (147). The rape trauma syndrome is a constellation of physical and psychological symptoms, including fear, helplessness, disbelief, shock, guilt, humiliation, embarrassment, anger, and self-blame. Survivors may experience intrusive memories of the assault, blunting of affect, and hypersensitivity to environmental stimuli. They are anxious, do not feel safe, have difficulty sleeping and eating, and experience nightmares and a variety of somatic symptoms (116,150,151). In the weeks to months following the sexual assault, survivors often return to normal activities and routines. They may appear to have dealt successfully with the assault, but they may be repressing strong feelings of anger, fear, guilt, and embarrassment. In the months following the assault, survivors begin the process of integration and resolution. During this phase, they begin to accept the assault as part of their life experience, and somatic and emotional symptoms may decrease progressively in severity. Over the long term, survivors may have difficulty with work and with family relationships. Nearly half of the survivors lose their jobs or are forced to quit in the year following the rape, and half change their place of residency (133). Examination the responsibilities of physicians providing immediate treatment for sexual assault survivors are listed in Table 11. Because of the legal ramifications, consent must be obtained from the patient before obtaining the history, performing the physical examination, and collecting forensic evidence. Documentation of the handling of specimens is especially important, and the chain of evidence for collected material must be carefully maintained. Everyone who handles the evidence must sign for it and hand it directly to the next person in the chain. The chain of evidence extends from the examiner, to the police detective, to the crime laboratory, and finally to the courtroom. The patient should be interviewed in a quiet and supportive environment by an examiner who is objective and nonjudgmental. Support personnel and patient advocates, such as family, friends, or, if available, a counselor from a rape crisis service, should be encouraged to accompany the patient. It is important not to leave the survivor alone and to give her as much control as possible over the examination. To provide useful forensic information, the examination should be performed as soon as possible after the incident occurred. Providers in all 50 states are required to report all cases of suspected or known childhood sexual abuse to appropriate authorities. The history should include the following information: A general medical history and a gynecologic history must be obtained, including last menstrual period; prior pregnancies; past gynecologic infections; tetanus immune status; history of liver disease, thrombosis, or hypertension (possible contraindications to emergency contraception with estrogens); contraceptive use; prior sexual assault; and last consensual intercourse before the assault. It is important to ascertain whether the survivor bathed, douched, used a tampon, urinated, defecated, used an enema, brushed her teeth or used mouthwash, or changed her clothes after the assault. A detailed description of the sexual assault should be obtained, including the place, time, and date of the assault; number and appearance of assailants; use of drugs or alcohol in relation to the assault; loss of consciousness; use of weapons, threats, and restraints; and any physical injuries that may have occurred. A detailed description of the type of sexual contact must be obtained, including whether vaginal, oral, or anal contact or penetration occurred; insertion of a foreign object with a description of the object; whether the assailant used a condom; and whether there were other possible sites of ejaculation or oral contact, such as the hands, clothes, breasts, or hair of the survivor. The physical examination serves to detect, evaluate, and treat all injuries and to collect forensic evidence (152). The survivor should undress while standing on clean examination table paper to catch any hair or fibers falling from her clothing. During the physical examination, the degree of injury to the survivor should be assessed, and any injuries should be documented for use as evidence. The nature, size, and location of all injuries should be carefully documented, using photographs or body charts (traumagram) if possible. Ultraviolet photography may enable the examiner to record injuries not seen with standard photographic equipment, such as bite marks, stains, blood, or weapon imprints. Nongenital injuries occur in 20% to 50% of all rapes, so it important to carefully examine the entire body (152,153). The most common injuries are bruises and abrasions of the head, neck, and arms, and genital injuries accompanied by bleeding and pain (150). Hair and skin should be examined for dirt, foreign material, dried blood, and dried semen (152). If oral penetration has taken place, injuries of the mouth and pharynx may occur (154). Injury to the oral cavity, including a torn frenulum, broken teeth, trauma to the uvula, and injuries of the hard and soft palate, are related to forced fellatio. Evidence of trauma is more likely when the assault has occurred out of doors or is perpetrated by a stranger (155). The most common genital findings are erythema and small tears of the vulva, perineum, and introitus. A Foley catheter, placed in the distal vaginal vault and then inflated, allows for full visualization of hymenal injuries (138). There may be bleeding, mucosal tears, erythema, or a hematoma noted around the rectum if penetration occurred. Identification of small lacerations of the genitalia or rectum may be aided by colposcopy or by staining with toluidine blue, which has an affinity for the nuclei of exposed submucosal cells and will make the injuries stand out (153,154,156). Toluidine blue should be applied before the speculum examination, as insertion of the speculum itself can cause small lacerations and false-positive results. Toluidine blue is spermicidal and should not be applied until all forensic evidence is collected (156). Impressions and photographs of bite marks can be made and used to help identify the assailant. Samples should be obtained from any sites of contact (vagina, rectum, or mouth) and tested for gonorrhea and chlamydia. Urine and blood samples should be collected to screen for the presence of any date rape drugs. Evidence must be properly collected for legal purposes according to the following procedures: Examination of the patient with a Wood light may help identify semen, which will fluoresce blue-green to orange. Areas of fluorescence should be swabbed with a cotton-tipped applicator moistened with sterile water, then air dried and submitted as evidence. Swabs of the skin, vagina, mouth, breasts, and rectum may be obtained to test for the presence of sperm or semen. In general, use a dry swab to obtain evidence from wet areas, and a wet swab to obtain evidence from dry areas. A sample of the vaginal secretions should be obtained for examination for motile sperm, semen, or pathogens.

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