MDM - Animal Bite

[##]-year-old [male/female] with [animal] bite to the [location] with history and exam consistent with [low/moderate/high] risk for infection.

Initial consideration in this patient included risk for deep space infection, tendon injury, risk for rabies, risk for tetanus, and penetration into joint cavity amongst others.

Patient presented with [abrasions/lacerations] to the [location with/without] evidence of purulent drainage or significant contamination to the wounds.  Patient noted to have full active and passive range of motion of the [location] despite pain.  Patient noted to have [no] evidence of [specify] tendon injury.  Plain films were obtained [with/without] evidence of foreign body.  Wounds cleaned and dressed in the ED prior to discharge. 

Tetanus status was [noted to be up to date/unknown with patient vaccinated in the ED] prior to discharge.  Risk of rabies was considered [a possibility given unknown vaccination status of the animal that bit the patient/unlikely given report of vaccinated animal with no evidence of unusual or aggressive behavior].  Administration of rabies immunoglobulin and vaccine [felt to not be indicated at this time/performed in the ED prior to discharge with discussion of appropriate follow up for additional doses of rabies vaccine prior to discharge].

Discussed discharge with [analgesics/prophylactic antibiotics], and follow up with [primary care doctor/Orthopedics/Occupational Health] in [48 hours/2-3 days], and the patient demonstrated understanding and agreement.