© 2000 T-System, Inc. EXTREMITIES __uninjured, nml inspection __neuro / vasc / tendon function intact 21 __see diagram EMERGENCY PHYSICIAN RECORD Animal Bite (3) TIME SEEN:______________ ROOM:___________ __ EMS Arrival HISTORIAN: __patient __spouse __paramedics __HX / __EXAM LIMITED BY: ambulance notes reviewed chief complaint: BITE occurred: __just prior to arrival __today __yesterday where: __home __neighbor's __work w/comp __school __park __street animal: __dog __cat __other: __family pet __neighborhood animal __unknown animal Appearance of animal __appeared well __appeared ill __unknown Description: Animal’s Immunization status __UTD __unknown __not immunized Observation/capture... __animal is known; can be observed for 10 days __animal unknown; not captured __animal control notified circumstances of attack: __"unprovoked" attack. __"provoked" attack (see below) __approached animal __entered animal's domain __animals fighting __playing with or teasing animal __other severity of injury: __bitten __scratched __mucous membrane contact location of injury: head face neck chest abdomen back ( upper mid- lower ) shoulder R / L hip R / L RUE LUE RLE LLE ROS __tingling / numbness distally __suspected FB ( skin lac. ) __painful / unable to bear weight PAST HISTORY : __negative Meds- __none / __see nurses note Allergies- __NKDA / __see nurses note SOCIAL HISTORY : Nurses note reviewed PHYSICAL EXAM Tetanus immun. UTD Vital signs reviewed __Alert Distress- __NAD __mild __moderate __severe HEENT __see diagram __ENT uninjured, nml inspctn __eye lids / conjun. uninjured NECK __see diagram __uninjured, nml inspection CHEST __see diagram __uninjured, nml inspection ABDOMEN __see diagram __uninjured, nml inspection BACK __see diagram __uninjured, nml inspection Circle- positive __Check-normal Backslash-negative (see reverse for further diagrams of hands and feet) T=Tenderness PtT=Point Tenderness S=Swelling E=Ecchymosis B=Burn C=Contusion Lac=Laceration A=Abrasion M=Muscle spasm (∅=without m=mild mod=moderate sv=severe) Example- Tsv = Tenderness on palpation (severe) ADDRESSOGRAPH XRAYS Interp. by me __nml / NAD __no fracture __nml alignment Reviewed by me Discsd w/radiologist __soft tissue swelling / deficit __fracture / dislocation __nml soft tissue OTHER See separate report PROCEDURES and PROGRESS Wound Description/Repair length________cm location_____________________________ __superficial __SQ __muscle __linear __stellate __irregular distal NVT: __sensation nml distally __vascular intact __motor nml distally __no muscle/tendon injury anesthesia: __local ______________ ________cc __lidoc 1% 2% epi / bicarb __marcaine .25% .5% prep: __Hibiclens / Shur-Clens / Betadine / Neosporin __^debrided / undermined __irrigated/washed w/ saline *extensively *extensively __foreign material removed w/ pressure __explored minimal moderate ^ extensive repair: Wound closed with: wound adhesive / Dermabond / steri-strips SKIN#______ _____-0 nylon / prolene / staples SUBCU #______ _____-0 vicryl / chromic MUSCLE/FASCIA #_____ _____-0 vicryl / *may indicate intermediate repair ^ may indicate intermediate or complex repair __Prior records ordered __Rx given __Discussed with Dr. Time: will see patient in: office / ED / hospital CLINICAL IMPRESSION : Animal Bite Laceration Puncture Wound Dog Cat Bite Scratch R/L R/L R/L R/L R/L R/L R/L R/L head face chest abdomen back DISPOSITIONCONDITION- home eloped good stable arm forearm hand wrist thigh leg ankle foot admitted transferred expired Obs LWBS Other fair poor critical improved unchanged AMA PA MD / DO Template Completed Animal Bite - 21 Dictated Addendum
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