CHIEF COMPLAINT: Dog bite to right cheek.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who was bitten in the right cheek by her neighbor's dog. Mother states the dog's immunizations are up-to-date as well as the child's. The patient presents mostly with some scrape wounds, but then a small puncture wound was noted to the inferior aspect of the right cheek. There is minimal bleeding.
REVIEW OF SYSTEMS: Otherwise negative.
PAST MEDICAL HISTORY: No major illnesses.
ALLERGIES: None.
CURRENT MEDICATIONS: None.
PHYSICAL EXAMINATION: Temperature 99.2, pulse 96, respirations 22, BP 98/64. Examination of the face shows multiple abrasions of most of the right maxillary region with a less than 1 cm superficial laceration noted at the right cheek just lateral to the right side of the lips. This does not involve the lips or the vermilion border. There is minimal depth to this.
PROCEDURE: The area was prepped and draped in sterile fashion. It was cleansed appropriately. It was closed with Dermabond with good cosmetic appearance. This was discussed with parents prior to closure, of whether to use Dermabond or sutures, and they preferred Dermabond. They were also instructed on the possibility of infection due to the fact that this is a dog bite wound.
IMPRESSION:
1. Dog bite to right cheek.
2. Laceration with repair, less than 1 cm.
PLAN:
1. Dermabond instruction sheet was given.
2. Return as needed.
3. Follow up with family medical doctor.
4. Given a prescription for Augmentin.
Sample #2
CHIEF COMPLAINT: Dog bite.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who was attempting to restrain his dog from going outside. He states the dog then bit him on his right foot at the fifth toe. He states when he reached down to pull the dog off of his foot, the dog then bit him in the left hand, in the webspace between his thumb and second digit. The patient states the bleeding is now under control. He denies any numbness, tingling or weakness of his hand or foot.
IMMUNIZATION STATUS: Last tetanus shot was less than 5 years ago.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Nonsmoker, drinks alcohol occasionally, denies any illicit drug use.
REVIEW OF SYSTEMS: As above. Otherwise negative, per patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/84, pulse 72, respirations 22, temperature 98.6, O2 sat is 100% on room air.
GENERAL: A well-developed, well-nourished male, in no acute distress.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: The patient does have an approximately 2.5 cm in diameter laceration to his left hand, on the dorsal aspect of his hand, in the webspace between the thumb and index finger. The wound is slightly gaping. There is no involvement of tendons or any vasculature. He has full range of motion of his thumb and second digit, 2+ pulses bilaterally. He does have a fairly extensive 2.5 cm laceration noted to his right foot on the plantar aspect, just proximal to his fifth digit. The wound is fairly deep but does not extend into the tendons or vasculature. The patient has full range of motion of his toes. He has capillary refill less than 2 seconds.
NEUROLOGIC: He is alert and oriented x 4. Gross sensation is intact. Strength is 5/5 bilaterally.
EMERGENCY DEPARTMENT COURSE: The patient's nursing notes were reviewed. The patient did have a right foot x-ray. X-ray negative for any fracture or foreign bodies.
PROCEDURE PERFORMED:
The wound on the patient's hand was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. The area was then copiously irrigated with normal saline. It was then prepped and draped in a sterile fashion, and one simple interrupted suture was placed using 4-0 Ethilon to approximate the wound. The remainder of the wound was left open in order to avoid trapping any bacteria. The wound was then covered with a sterile dressing. Attention was then turned to the patient's right foot. This area was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. That area was then copiously irrigated with normal saline. The wound was then explored to reveal a fairly deep wound. Did not appear to involve any deeper structures, but we did consult Podiatry given the high risk of infection.
Podiatry came and evaluated the patient. Dr. John Doe did apply bacitracin as well as a sterile dressing and Coban. The patient was given a cast shoe and crutches in order to remain nonweightbearing on the foot. They did not close the wound with any sutures.
MEDICAL DECISION MAKING: At this time, the patient does have 2 dog bites that do have a high risk of infection. At this time, we will place the patient on Augmentin, and he will be followed closely by Podiatry. We will have him keep an eye on his wound to ensure there are no signs of infection.
DIAGNOSIS: Dog bite to left hand and right foot.
PLAN:
1. The patient is given Augmentin and Vicodin #10.
2. The patient is to keep the area clean and dry.
3. He is to change his dressing, of his foot, daily with bacitracin, 4 x 4, and Ace wrap.
4. He is to wear his cast shoe and use crutches until he follows up with Podiatry. He is scheduled to follow up with Podiatry. He is to call for an appointment.
5. He is also to call a community clinic of choice for an appointment to have his sutures removed in 10 to 14 days.
6. Again, the patient was instructed to watch the wound closely for any signs of infection, redness, swelling, pus drainage, increased pain or fever.
7. The patient is to return to the emergency room for any signs of infection or any other concerns.
CONDITION: Good.
DISPOSITION: The patient was discharged home.
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HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who was bitten in the right cheek by her neighbor's dog. Mother states the dog's immunizations are up-to-date as well as the child's. The patient presents mostly with some scrape wounds, but then a small puncture wound was noted to the inferior aspect of the right cheek. There is minimal bleeding.
REVIEW OF SYSTEMS: Otherwise negative.
PAST MEDICAL HISTORY: No major illnesses.
ALLERGIES: None.
CURRENT MEDICATIONS: None.
PHYSICAL EXAMINATION: Temperature 99.2, pulse 96, respirations 22, BP 98/64. Examination of the face shows multiple abrasions of most of the right maxillary region with a less than 1 cm superficial laceration noted at the right cheek just lateral to the right side of the lips. This does not involve the lips or the vermilion border. There is minimal depth to this.
PROCEDURE: The area was prepped and draped in sterile fashion. It was cleansed appropriately. It was closed with Dermabond with good cosmetic appearance. This was discussed with parents prior to closure, of whether to use Dermabond or sutures, and they preferred Dermabond. They were also instructed on the possibility of infection due to the fact that this is a dog bite wound.
IMPRESSION:
1. Dog bite to right cheek.
2. Laceration with repair, less than 1 cm.
PLAN:
1. Dermabond instruction sheet was given.
2. Return as needed.
3. Follow up with family medical doctor.
4. Given a prescription for Augmentin.
Sample #2
CHIEF COMPLAINT: Dog bite.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who was attempting to restrain his dog from going outside. He states the dog then bit him on his right foot at the fifth toe. He states when he reached down to pull the dog off of his foot, the dog then bit him in the left hand, in the webspace between his thumb and second digit. The patient states the bleeding is now under control. He denies any numbness, tingling or weakness of his hand or foot.
IMMUNIZATION STATUS: Last tetanus shot was less than 5 years ago.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Nonsmoker, drinks alcohol occasionally, denies any illicit drug use.
REVIEW OF SYSTEMS: As above. Otherwise negative, per patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/84, pulse 72, respirations 22, temperature 98.6, O2 sat is 100% on room air.
GENERAL: A well-developed, well-nourished male, in no acute distress.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: The patient does have an approximately 2.5 cm in diameter laceration to his left hand, on the dorsal aspect of his hand, in the webspace between the thumb and index finger. The wound is slightly gaping. There is no involvement of tendons or any vasculature. He has full range of motion of his thumb and second digit, 2+ pulses bilaterally. He does have a fairly extensive 2.5 cm laceration noted to his right foot on the plantar aspect, just proximal to his fifth digit. The wound is fairly deep but does not extend into the tendons or vasculature. The patient has full range of motion of his toes. He has capillary refill less than 2 seconds.
NEUROLOGIC: He is alert and oriented x 4. Gross sensation is intact. Strength is 5/5 bilaterally.
EMERGENCY DEPARTMENT COURSE: The patient's nursing notes were reviewed. The patient did have a right foot x-ray. X-ray negative for any fracture or foreign bodies.
PROCEDURE PERFORMED:
The wound on the patient's hand was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. The area was then copiously irrigated with normal saline. It was then prepped and draped in a sterile fashion, and one simple interrupted suture was placed using 4-0 Ethilon to approximate the wound. The remainder of the wound was left open in order to avoid trapping any bacteria. The wound was then covered with a sterile dressing. Attention was then turned to the patient's right foot. This area was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. That area was then copiously irrigated with normal saline. The wound was then explored to reveal a fairly deep wound. Did not appear to involve any deeper structures, but we did consult Podiatry given the high risk of infection.
Podiatry came and evaluated the patient. Dr. John Doe did apply bacitracin as well as a sterile dressing and Coban. The patient was given a cast shoe and crutches in order to remain nonweightbearing on the foot. They did not close the wound with any sutures.
MEDICAL DECISION MAKING: At this time, the patient does have 2 dog bites that do have a high risk of infection. At this time, we will place the patient on Augmentin, and he will be followed closely by Podiatry. We will have him keep an eye on his wound to ensure there are no signs of infection.
DIAGNOSIS: Dog bite to left hand and right foot.
PLAN:
1. The patient is given Augmentin and Vicodin #10.
2. The patient is to keep the area clean and dry.
3. He is to change his dressing, of his foot, daily with bacitracin, 4 x 4, and Ace wrap.
4. He is to wear his cast shoe and use crutches until he follows up with Podiatry. He is scheduled to follow up with Podiatry. He is to call for an appointment.
5. He is also to call a community clinic of choice for an appointment to have his sutures removed in 10 to 14 days.
6. Again, the patient was instructed to watch the wound closely for any signs of infection, redness, swelling, pus drainage, increased pain or fever.
7. The patient is to return to the emergency room for any signs of infection or any other concerns.
CONDITION: Good.
DISPOSITION: The patient was discharged home.
ER Sample Reports ER Sample Reports # 1
