Counselling · Foundation · Infectious Diseases

Puncture Wound to Hand Following Dog Bite

Practise this PLAB 2 counselling station on Dog Bite Wound. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in an emergency department. Miss Harriet Nolan, a 34-year-old woman, has attended with a puncture wound to her left hand sustained approximately two hours ago when a dog bit her during a walk in the park. Please take a brief history, examine the wound, and discuss management including wound care, tetanus prophylaxis, antibiotic prophylaxis, and rabies risk assessment.

Background notes: PMH: Eczema (mild, winter)

What this station tests

  • Hand bite as high-risk location: proximity to joints, tendons, and poor vascularity requiring prophylactic antibiotics
  • Prophylactic antibiotic criteria: hand bites, puncture wounds, immunocompromised, delayed presentation
  • Not suturing puncture wounds: closure traps bacteria and increases infection risk
  • Rabies is not endemic in the UK: domestic dog bites in the UK do not require rabies PEP
  • Tetanus status check: determining whether a booster or immunoglobulin is needed

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Animal bite wounds require assessment for wound severity, infection risk, tetanus status, and rabies risk. Miss Nolan is 34, with a puncture wound to her left hand from a dog bite 2 hours ago. She is worried about infection, scarring, and rabies. Open with: 'Miss Nolan, let me take a look at the wound and ask you some important questions about what happened.'

Core approach

Assess the wound. Puncture wound on left hand (hands are high-risk for bite infection due to proximity to joints, tendons, and poor vascularity). Check neurovascular status distally (sensation, motor function, capillary refill). Any tendon involvement? Can she fully flex and extend all fingers? Any joint penetration? Hand bites need careful assessment because of the complex anatomy.

Infection risk. Dog bites: 5 to 15% infection rate (lower than cat bites at 30 to 50%). Puncture wounds are higher risk than lacerations. Hand location is higher risk. Common organisms: Pasteurella multocida, streptococci, staphylococci, anaerobes. Prophylactic antibiotics are indicated for: hand bites, puncture wounds, immunocompromised patients, and bites with delayed presentation (>12 hours). Co-amoxiclav is first-line.

Tetanus status. When was her last tetanus booster? If fully immunised (5 doses in childhood/adolescence), no booster needed. If uncertain or incomplete: tetanus immunoglobulin and booster.

Rabies. The dog was a domestic pet in the UK. Rabies is not endemic in the UK. Rabies PEP is not needed for domestic dog bites in the UK. If the bite occurred abroad in a rabies-endemic country, management would be different.

Closing and safety netting

Wound management: irrigate thoroughly with saline (reduces infection risk significantly). Do not suture puncture wounds (traps bacteria). Dress cleanly. Prophylactic co-amoxiclav (or doxycycline plus metronidazole if penicillin allergic) for 5 days given the hand location and puncture type.

Reassure about rabies: 'In the UK, domestic dogs do not carry rabies. You do not need rabies treatment.' Address scarring: 'Puncture wounds generally heal well with minimal scarring.' X-ray if foreign body or fracture suspected (tooth fragment).

Safety net: 'If the wound becomes increasingly red, swollen, painful, or you develop a fever within the next 48 hours, come back urgently as bite wounds can become infected quickly.' Follow-up wound check in 48 hours. Report the dog bite to environmental health or the police if the dog was dangerous.

How examiners mark this station

Examiners will assess your ability to explain dog bite wound and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Wound assessed (depth, neurovascular status, tendon involvement). Infection risk stratified (hand, puncture). Tetanus status checked. Rabies risk assessed (UK, domestic dog). Circumstances documented.

Costs marks: Not assessing hand function. Not checking tetanus. Not assessing infection risk factors.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Wound irrigation. Not suturing. Prophylactic co-amoxiclav. Tetanus managed appropriately. Rabies PEP not needed (UK). 48-hour wound check. Infection safety netting.

Costs marks: Suturing puncture wound. No antibiotics. Unnecessary rabies PEP. No follow-up.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing rabies concern directly and reassuring. Explaining infection risk practically. Providing clear wound care instructions. Acknowledging her anxiety.

Costs marks: Not addressing rabies concern. Being vague about infection signs. Not providing practical advice.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Not giving prophylactic antibiotics. Hand bites and puncture wounds both independently warrant prophylaxis. A hand puncture wound is a double indication. Candidates who clean and dress without prescribing antibiotics provide inadequate management.
  2. Suturing the wound. Puncture wounds from animal bites should not be sutured as closure traps bacteria. Candidates who suture increase infection risk.
  3. Providing unnecessary rabies PEP. Rabies is not endemic in UK domestic animals. Candidates who discuss rabies treatment for a UK domestic dog bite demonstrate geographical knowledge gap.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this dog bite wound counselling consultation?

Animal bite wounds require assessment for wound severity, infection risk, tetanus status, and rabies risk. Miss Nolan is 34, with a puncture wound to her left hand from a dog bite 2 hours ago. She is worried about infection, scarring, and rabies.

Where are marks won and lost in this dog bite wound station?

Examiners reward: Wound assessed (depth, neurovascular status, tendon involvement). Infection risk stratified (hand, puncture). Tetanus status checked. Rabies risk assessed (UK, domestic dog). Candidates are penalised for: Not assessing hand function. Not checking tetanus. Not assessing infection risk factors.

Where do candidates most often go wrong in this station?

Not giving prophylactic antibiotics. Hand bites and puncture wounds both independently warrant prophylaxis. A hand puncture wound is a double indication.

Can I do well in this station without real-world experience of dog bite wound?

Structure beats experience here. Focus on prophylactic antibiotic criteria: hand bites, puncture wounds, immunocompromised, delayed presentation. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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