CHIEF COMPLAINT: Dog bite to right foot.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old otherwise healthy African American female who presented to the emergency department with the above complaint. The patient states at approximately 2:00 this afternoon, she was bit by a chihuahua.
The patient states she did, at that time, ask the owner if the dog’s vaccinations are up-to-date and they are current per the owner. The patient states that, when she returned home, she thoroughly cleaned out the area and put some Neosporin and a bandage on there.
The patient states she then still had some pain and thought she needed followup. The patient describes this as a throbbing, achy sensation, rating it a 8/10. The patient has not yet taken over-the-counter Tylenol or ibuprofen for this pain. The patient is unsure when her last tetanus vaccination was; however, the patient states she does know it was greater than 5 or 6 years ago.
The patient currently has no primary physician to see regarding this. The patient denies any numbness or tingling of that extremity or decreased range of motion. The patient also denies any other puncture wounds secondary to this bite.
PAST MEDICAL HISTORY: The patient denies.
CURRENT MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smokes 1 pack of cigarettes a day. He denies use of alcohol and illicit or IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/82, pulse 66, respirations 22, temperature 98.8 and O2 saturation 99% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old female who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative and communicates well and was ambulatory here in the emergency department.
HEENT: Normocephalic and atraumatic. Eyes: Equal, round and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctivae are pink without discharge. Sclerae are nonicteric. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops noted.
ABDOMEN: Soft, nondistended, nontender to palpation in all 4 quadrants. There is no rebound or guarding noted. No masses noted either. Bowel sounds present in all 4 quadrants.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion of all extremities. Sensation is intact to light touch. Muscle strength is 5/5 of all extremities. Upon further examination of the patient’s right lower extremity, she has 2+ dorsal pedis and posterior tibialis pulses. The patient has intact sensation to light touch. The patient does have a small puncture wound noted to the dorsal aspect of her right foot with no active bleeding. The patient has no puncture wounds noted. Upon examination, we did not notice any foreign body. The patient had full dorsi and plantarflexion of that foot. The patient had no edema or drainage from this area. The patient had brisk capillary refill.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. Muscle strength 5/5 of all extremities. No focal deficits noted.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, her tetanus vaccination was updated here in the emergency department. The patient also had her wound thoroughly irrigated. Antibiotic ointment and dressing was applied. The patient tolerated this well.
IMPRESSION: This is a (XX)-year-old female who presents to the emergency department for a dog bite to her right foot. Upon examination, the patient was neurologically intact and no foreign body was noted. The patient did have a small puncture wound to the dorsal aspect of her right foot, which was thoroughly irrigated and a sterile dressing was applied. At this time, we do feel the patient is stable for discharge home, and she will be discharged with a prescription for Augmentin. The patient will also be given a clinic list for followup for persistent symptoms. The patient will also be given the next couple of days off of work.
DIAGNOSIS: Dog bite to the right foot.
PLAN:
1. Augmentin 875 mg.
2. Wound care instructions.
3. Tylenol, ibuprofen as needed for pain.
4. Elevate for swelling.
5. Follow up with PCP.
6. Return for any signs of infection such as increased redness, swelling, purulent drainage or other concerns.
DISPOSITION: The patient was discharged to home in stable condition.
