Sexual Assault Nurse Examiner Case
Melissa Goslawski

Real case redacted from files from 2024 with Discussion Following

Patient presents as a 26 y/o single white female who is currently pregnant at 3w1d. She has a past medical history of bipolar disorder where she takes Lithium, although noncompliant 2-3 days before hospital admission. Patient states she had consensual vaginal intercourse about 2 days prior to exam and assault. She had symptoms of UTI on admit. She was awake to person, place, time and situation. Her gate was steady, with slow cognition. Her affect was slow, and it was difficult to focus patient on topic during exam.

Case discussion

When a patient presents to the ER for evaluation after sexual assault, every case must be taken seriously and methodically. Unfortunately, there are times where patients present with complaints of sexual assault that may be difficult to discern if they were actual offenses or a product of the patient’s delusion. Those with bipolar disorder when manic, often engage in risky sexual behavior. Furthermore, women who become pregnant have a higher risk of becoming manic or depressed (25-30%) with higher rates of illness recurrence during pregnancy after stopping mood stabilizers.

Key points in this case warrant further evaluation by psychiatry. She does appear with slow cognition, and difficulty with concentration during the interview. She also comments on seeing “bears and roaches” on the walls, which show signs of possible hallucinations. Are these pictures or actual animals? More information is needed. Risky sexual behavior can also be a symptom of mania. There are signs too that this patient may be a dangerous to herself, allowing herself to be placed in dangerous situations. There was no evidence of assault on vaginal or anal exam, and no strangulation marks on the neck. While these are difficult to detect, they could possibly have been detected sooner after the assault took place and with a high-definition camera, which was not used in this case.

The patient in this case would be recommended for evaluation of psychiatry and for safety and possible inpatient admission for mood stabilization. Again, many patients in these situations can also be victims of sexual abuse, so even threats of such abuse should be done systematically and professionally. In cases of repeat allegations with a negative physical exam, this provides further evidence to the psychiatric team that the allegations may be a product of the patient’s delusions.

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