What is the initial management for a patient presenting with an animal bite, considering assessment of severity, risk of infection, and relevant medical history, including tetanus vaccination status and potential need for antibiotics, such as amoxicillin-clavulanate (Augmentin) or doxycycline?

Animal Bite OSCE Case for OPD

CASE SCENARIO

Patient Presentation: A 28-year-old male presents to the OPD 4 hours after being bitten by a neighbor's dog on his right hand (dorsum, near the first metacarpal). The wound is approximately 3 cm long, with puncture marks and mild bleeding. The patient is concerned about infection and doesn't remember his last tetanus shot.

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CANDIDATE INSTRUCTIONS

You have 10 minutes to:

1. Take a focused history
2. Examine the wound appropriately
3. Formulate and explain your management plan
4. Address the patient's concerns

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EXAMINER CHECKLIST

HISTORY TAKING (20 points)

Details of the Bite Injury:

• Time elapsed since bite occurred 1
• Type of animal (dog/cat/wild/domestic) 1
• Provoked vs unprovoked attack 1
• Location and depth of wound 1
• Whether animal is known to patient 2
• Vaccination status of the animal (rabies) 1
• Current location/availability of animal for observation 1

Patient Risk Factors:

• Tetanus immunization status (last dose within 5 years?) 1, 3
• Immunocompromised status (HIV, diabetes, cancer, steroids, chemotherapy) 1
• Asplenia 1
• Advanced liver disease 1
• Penicillin allergy 1
• Current medications 1

Wound-Specific Risk Assessment:

• Hand/face involvement (high-risk locations) 1
• Puncture wound vs laceration 1, 2
• Pre-existing edema of affected area 1

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PHYSICAL EXAMINATION (20 points)

Wound Assessment:

• Inspects wound for depth and extent 2
• Assesses for active bleeding 2
• Checks for foreign bodies (teeth fragments) 1, 4
• Evaluates for tendon involvement (tests finger/hand movements) 1, 2
• Assesses for bone/joint penetration (pain disproportionate to injury near bone/joint) 1
• Checks for nerve damage (sensation testing) 1, 3
• Examines for signs of infection (erythema, warmth, purulent discharge, lymphangitis) 1, 5

Systemic Assessment:

• Checks regional lymph nodes 5
• Assesses neurovascular status distal to wound 3

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IMMEDIATE WOUND MANAGEMENT (25 points)

Wound Cleansing:

• Copious irrigation with sterile normal saline using 20-mL or larger syringe 1, 2
• Avoids iodine or antibiotic-containing solutions for irrigation 1
• Removes superficial debris 1
• Performs cautious debridement of devitalized tissue only (avoids enlarging wound) 1

Wound Closure Decision:

• Correctly identifies that hand wounds should NOT be closed primarily 1
• States that facial wounds are exception and can be closed after meticulous care 1, 3
• Plans for delayed primary or secondary closure 1
• Approximates margins with Steri-Strips if appropriate 1

Elevation and Immobilization:

• Recommends elevation of affected hand 1
• Considers immobilization with sling 1

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ANTIBIOTIC MANAGEMENT (20 points)

Prophylactic Antibiotic Decision:

• Correctly identifies this as high-risk wound requiring preemptive antibiotics (hand location, puncture wound, <12-24 hours presentation) 1
• States indications: immunocompromised, asplenic, liver disease, edema, moderate-severe injury, hand/face, periosteum/joint penetration 1

Antibiotic Selection:

• Prescribes amoxicillin-clavulanate 875/125 mg twice daily as first-line 1, 6
• States duration of 3-5 days for prophylaxis 1, 3
• Provides alternative for penicillin allergy: doxycycline 100 mg twice daily 1
• Explains that first-generation cephalosporins and macrolides are inadequate (poor Pasteurella coverage) 1, 3
• Mentions need for extended therapy (2-4 weeks) if osteomyelitis/septic arthritis develops 1

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TETANUS AND RABIES PROPHYLAXIS (10 points)

Tetanus Management:

• Administers tetanus toxoid 0.5 mL IM if >5 years since last dose or status unknown 1, 3
• Prefers Tdap over Td if not previously given 3

Rabies Assessment:

• States need to consult local health department regarding rabies prophylaxis 1, 3
• Explains that domestic dogs should be observed for 10 days 1
• Mentions rabies immunoglobulin + vaccine series (days 0,3,7,14) if indicated 1, 2
• States that wild/feral animals or unavailable animals require immediate prophylaxis 1

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FOLLOW-UP AND PATIENT EDUCATION (5 points)

Follow-up Plan:

• Schedules follow-up within 24 hours (phone or office visit) 1
• Instructs patient on warning signs: increasing pain, redness, swelling, purulent discharge, fever, red streaks 1, 3
• Advises immediate return if infection progresses despite antibiotics 1

Patient Counseling:

• Explains importance of completing full antibiotic course 6
• Warns about potential diarrhea from antibiotics 6
• Advises taking amoxicillin-clavulanate with food to reduce GI upset 6

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CRITICAL ERRORS (Automatic Failure)

• Closes hand wound primarily (high infection risk) 1
• Fails to prescribe antibiotics for high-risk hand bite 1
• Prescribes inadequate antibiotic (e.g., cephalexin alone, azithromycin) 1, 3
• Fails to address tetanus status 1, 3
• Fails to consider rabies prophylaxis 1
• Does not arrange follow-up within 24 hours 1

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COMMON PITFALLS TO AVOID

Wound Management Errors:

• Using inadequate irrigation volume or pressure 2
• Aggressive debridement that enlarges wound unnecessarily 1
• Primary closure of infected or high-risk wounds 1

Antibiotic Errors:

• Relying on topical antibiotics alone (explicitly inadequate for bite wounds) 3
• Using first-generation cephalosporins (poor Pasteurella coverage) 1, 3
• Prescribing clindamycin alone (misses Pasteurella) 3
• Failing to extend therapy if deep infection develops 1

Assessment Errors:

• Missing tendon/nerve/bone involvement 1, 3
• Inadequate exploration for foreign bodies 1, 4
• Failing to recognize pain disproportionate to injury (suggests periosteal penetration) 1

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STANDARDIZED PATIENT INSTRUCTIONS

Opening Statement: "Doctor, I was bitten by my neighbor's dog about 4 hours ago while trying to pet it. My hand is really hurting and I'm worried about infection. I don't think I've had a tetanus shot in years."

If Asked About Animal:

• Dog is a 3-year-old Labrador, usually friendly
• Owner says dog is vaccinated for rabies but you haven't seen papers
• Dog is at owner's house and appears healthy

If Asked About Medical History:

• No diabetes, no immune problems
• No known drug allergies
• No current medications
• Cannot remember last tetanus shot (probably >10 years ago)

Concerns to Express:

• "Will I get rabies?"
• "Do I need stitches?"
• "Can I still use my hand?"
• "How long until it heals?"

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SCORING SUMMARY

Section	Points Earned	Points Possible
History Taking	___/20	20
Physical Examination	___/20	20
Wound Management	___/25	25
Antibiotic Management	___/20	20
Tetanus/Rabies	___/10	10
Follow-up/Education	___/5	5
TOTAL	___/100	100

Pass Mark: 70/100

Critical Errors Committed: ___ (Any critical error = automatic failure)