Bitten Again
Immune System
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F1.jpg"}},{"insert":"\n\n"},{"insert":"Once again, you are jolted awake by your neighbor\u0027s dog barking. \u0022How\u0027s a resident supposed to get any sleep?\u0022 you think sarcastically as you peer at your phone screen.\r\n\r\n\u0022At least it\u0027s 6 a.m. this time,\u0022 you mutter as you crawl out of bed.\n"}]}
1
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F2.jpg"}},{"insert":"\n\n"},{"insert":"As you head out for the day, your favorite radio station helps you forget all about the barking dog as you hum along and focus on what might be awaiting you at the hospital.\r\n\r\nAs a bonus, the traffic is light. You are looking forward to a pleasant day!\n"}]}
2
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F3.jpg"}},{"insert":"\n\n"},{"insert":"You arrive at the hospital, and as you enter the emergency room, a patient is being wheeled towards an open cubicle. Everybody is too busy to exchange pleasantries.\r\n\r\n\u0022Gee \u2026 Even the docs on \u0022ER\u0022 got a \u0027good morning\u0027,\u0022 you grumble under your breath as you pull up the chart of the latest admission.\n"}]}
3
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F4.jpg"}},{"insert":"\n\n"},{"insert":"Mr. Graham is a weathered 61-year-old sheep farmer who seems somewhat annoyed, embarrassed and overwhelmed by all the attention.\r\n\r\n\u0022Doctor, it\u0027s just a little bite on my leg. I told my daughter it was nothing, but she called an ambulance anyway. I think she\u0027s overreacting,\u0022 Mr. Graham explains while forcing a smile.\n"}]}
4
{"ops":[{"insert":"\u0022Daisy is a great herding dog,\u0022 he begins. \u0022But she\u0027s been acting peculiar lately and about a week ago, she bit me.\r\n\r\n\u0022I know she didn\u0027t mean it. That dog\u0027s crazy about me. I\u0027ve never seen her act like that.\u0022 He shakes his head to underscore his bewilderment.\n"}]}
5
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F6.jpg"}},{"insert":"\n\n"},{"insert":"When you inquire about additional symptoms such as headaches, fever, tingling sensations around the wound site, and hallucinations or bizarre behavior, Mr. Graham denies them all.\r\n\r\n\u0022No, no, no and definitely NO, doctor,\u0022 he replies impatiently.\r\n\r\nYou look through Mr. Graham\u0027s records and discover he has been adequately immunized for tetanus and that his last booster dose was 7 years ago.\n"}]}
6
{"ops":[{"insert":"\u0022Mr. Graham, your dog \u2026 ,\u0022 you begin before he raises his hand to cut you off. \r\n\r\n\u0022Doctor, she\u0027s had her shots for the year. When the vet comes out to the farm to vaccinate the other animals, he always includes Daisy,\u0022 Mr. Graham says gazing around as if in search of the nearest exit.\n\n\u0022I mean, how has she been behaving since she bit you?\u0022, you probe further.\r\n\r\n\u0022She\u0027s not acting like herself,\u0022 Mr. Graham replies. \u0022She was hyperactive earlier but now she just retreats to a corner and wants to be left alone.\u0022\n"}]}
7
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F8.jpg"}},{"insert":"\n\n"},{"insert":"You ask permission to examine him to which he begrudgingly agrees.\r\n\r\nYou note he is healthy-looking and not in any obvious distress.\n\nMr. Graham\u0027s temperature is 36.8 \u00b0C, with a regular pulse rate of 82 bpm and respiratory rate of 18 breaths per min. His blood pressure is 118\/76 mmHg.\n"}]}
8
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M41_F9.jpg"}},{"insert":"\n\n"},{"insert":"The systemic examinations reveal no abnormalities except for the almost healed ~1 cm width puncture wound from the bite, in the right lower limb.\n\n\u0022I washed it with soap and water immediately and stuck on an adhesive bandage,\u0022 Mr. Graham says as you get a closer look at the wound.\r\n\r\nThe wound is clean with healthy-looking granulation tissue and mild erythema around the wound site.\n"}]}
9
{"ops":[{"insert":"You are well aware that the dog could be infected with the rabies virus and ask about its immunization status.\r\n\r\n\u0022May I see Daisy\u0027s vaccination records?\u0022 you ask.\n\nMr. Graham hesitates, \u0022Well, the problem is that I can\u0027t seem to find her certificate from the vet. I am positive though that she\u0027s had her shots this year.\u0022\n"}]}
10
{"ops":[{"insert":"What do you do next?\n"}]}
1. Administer human rabies immune globulin (HRIG) and commence the human diploid cell vaccine (HDCV)
2. Administer HDCV alone
3. Send Mr. Graham home and schedule a follow up
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