Skin Injury
Skin injury is damage to the integumentary tissue caused by mechanical, thermal, chemical, or radiation forces, ranging from superficial abrasions to full-thickness wounds involving the epidermis, dermis, and underlying structures.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Simple laceration / abrasion | Clean-cut or superficial wound, no deep structure involvement | 「個傷口係俾利嘢割到定係撞到？」(Sharp vs blunt?) |
| Contusion (bruise) | Blunt mechanism, intact skin, discolouration | Tenderness, swelling, ecchymosis on inspection | |
| Serious Not To Miss | Tendon / nerve / vascular injury | Loss of motor/sensory function distal to wound; pulsatile bleeding | 「手指郁唔郁到？有冇痺？」 [2][5] |
| Open fracture | Bone visible in wound; high-energy mechanism; deformity | 「見唔見到骨？隻手/腳有冇變形？」 [9] | |
| Wound infection / necrotising fasciitis | Disproportionate pain, systemic toxicity, dishwater pus [10] | 「個傷口有冇越嚟越紅腫痛？有冇發燒？」 | |
| Non-accidental injury (child abuse) | Inconsistent history, multiple injuries at different healing stages, delay | 「佢點樣整親嘅？」— check story consistency [1] | |
| Pitfalls | Retained foreign body | Penetrating mechanism (glass, metal); persistent pain/infection | 「有冇嘢入咗去傷口入面？」— XR if suspicious |
| Joint penetration | Wound near joint; pain on passive ROM; synovial fluid leak | Express joint fluid or saline load test | |
| Compartment syndrome | Pain on passive stretch, tense compartment, 6Ps | 「隻手/腳有冇越嚟越脹痛？」 | |
| Masquerades | Diabetes / peripheral neuropathy | Unaware of injury; chronic non-healing wound | 「你有冇糖尿病？腳有冇痺？」 [6] |
| Bleeding disorder / anticoagulant use | Excessive/prolonged bleeding from minor wound | 「你平時容易瘀？食緊薄血丸？」 | |
| Drugs (immunosuppressants/steroids) | Poor wound healing, recurrent infection | 「有冇食緊抑制免疫力嘅藥？」 | |
| Trying to Tell Me Something? | Domestic violence / self-harm | Hesitant history; injuries in unusual locations (inner arms, hidden areas); parallel cuts | 「你安唔安全㗎？屋企有冇人傷害你？」 |
| Workplace injury / compensation | Injury at work; asking about medical certificate | 「係咪返工嗰陣整親？需唔需要病假紙？」 | |
| Cosmetic anxiety | Repeated questions about scarring; facial wound | 「你最擔心嘅係咩？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生，今日由我幫你睇。你點稱呼呀？」「今日嚟有咩嘢我可以幫到你？」 | Patient-centred opening; establishes trust; interpersonal marks |
| 0:30–1:30 | Chief complaint & HPI — mechanism, timing, location, depth, bleeding, contamination, pain | 「可唔可以話我知發生咩事？」「幾時受傷嘅？」「點樣整親嘅？」「傷口有幾大幾深？」「有冇流好多血？」「有冇俾啲污糟嘢掂到個傷口？」 | Captures wound mechanism, severity, contamination — key for diagnosis and management |
| 1:30–2:30 | Red flags & associated injuries — neurovascular status, tendon function, bony injury, tetanus status, foreign body | 「隻手/腳郁唔郁到？有冇痺嘅感覺？」「有冇打過破傷風針？」「覺唔覺得入面有嘢卡住？」 | Screens for tendon/nerve/vascular injury; tetanus risk — marks for completeness |
| 2:30–3:30 | PMH, DHx, allergy, social Hx — DM, bleeding tendency, anticoagulants, smoking, occupation, immunosuppression | 「你有冇其他長期病？食緊咩藥？」「有冇藥物敏感？」「你做咩工作嘅？」「有冇食薄血丸？」 | Affects wound healing, infection risk, and management plan |
| 3:30–4:30 | ICE — uncover hidden agenda | 「你自己覺得個傷口點嚟嘅？」（Ideas）「你最擔心啲咩嘢？」（Concerns）「你今日嚟最想我幫你做啲咩？」（Expectations）「點解今日先嚟睇？」 | Critical for marks — "Why today?" often reveals hidden agenda (e.g., fear of scarring, infection, domestic violence, work injury compensation, child abuse concern) |
| 4:30–5:15 | Signpost examination & summarise | 「我想睇下你個傷口，可以嗎？」「等我總結一下你啱啱講嘅嘢…」 | Signposting and summarising score interpersonal marks |
| 5:15–6:00 | Closing: explain plan, safety-net, check understanding | 「我哋依家要幫你清洗傷口同處理。」「如果之後傷口越嚟越紅、腫、痛、有膿、或者發燒，要即刻返嚟睇。」「你有冇嘢想問？」 | Safety-net advice is a must; checking understanding shows patient-centredness |
Hidden agenda tips for Skin Injury:
- Ask 「點解今日先嚟睇？」— delayed presentation may indicate domestic violence, child abuse, self-harm, workplace injury claim, or fear of scarring/disfigurement.
- If the patient is a child brought by a carer, be alert for inconsistent history (non-accidental injury). [1]
- If the patient asks about cosmetic outcome → concern about scarring → expectations for plastic surgery referral.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Mechanism | How did you get injured? What caused the wound? | 「點樣整親嘅？係咩嘢整到？」 | Classification of injuries [2]: sharp/blunt/crush/bite/burn determines wound type and management | Stab → deep structure injury; bite → infection risk; burn → depth grading |
| Timing | When did the injury happen? | 「幾時整親？幾耐之前？」 | Wounds > 6–8 hours have higher infection risk; delayed closure contraindicated | Late presentation → infection; think of hidden agenda |
| Location & depth | Where is the wound? How deep is it? | 「傷口喺邊度？有幾深？見唔見到骨/筋？」 | Hand/face wounds need specialist referral; depth determines structure involvement | Tendon/nerve/vessel injury; joint penetration |
| Bleeding | How much did it bleed? Is it still bleeding? | 「流咗好多血？依家仲有冇流緊？」 | Profuse bleeding → vascular injury [2]; scalp lacerations bleed profusely [3] | Arterial injury; haemodynamic compromise |
| Contamination/FB | Was the wound contaminated? Any foreign body? | 「有冇俾泥、鐵釘、玻璃掂到？覺唔覺有嘢入咗去？」 | Contamination → infection/tetanus risk; retained FB → needs imaging | Wound infection [4]; tetanus; abscess |
| Neurovascular | Can you feel/move beyond the wound? | 「傷口以下嘅位置有冇痺？郁唔郁到手指/腳趾？」 | Nerve and vascular injury [2] — must document before any procedure | Nerve transection; compartment syndrome |
| Tendon function | Can you bend/straighten each finger? | 「每隻手指可唔可以曲直？」 | Common hand injuries [5] — tendon injury easily missed | Flexor/extensor tendon laceration |
| Tetanus | When was your last tetanus vaccination? | 「你上次打破傷風針係幾時？」 | Tetanus prophylaxis decision — high-yield management point | Need TIG + Td if not immunised |
| PMH | Any chronic diseases? Diabetes? | 「有冇長期病？糖尿病？」 | DM → impaired wound healing, infection risk [6] | Diabetic foot ulcer; poor healing |
| Medications | Taking blood thinners or steroids? | 「有冇食薄血丸？類固醇？」 | Anticoagulants → prolonged bleeding; steroids → poor healing | Warfarin/NOAC → bleeding tendency |
| Allergies | Any drug allergies? Latex allergy? | 「有冇藥物敏感？對膠手套敏感？」 | LA/antibiotic allergy affects wound management | Allergy to local anaesthetic, chlorhexidine [7] |
| Occupation | What is your job? | 「你做咩工作嘅？」 | Occupational injury → compensation; manual worker → functional impact | Workplace accident claim; needs MC |
| Domestic/NAI screen | (If history inconsistent) Can you tell me more about how this happened? | 「可唔可以再詳細啲講下點整親？」 | Non-accidental injury [1] — inconsistent history, delay in seeking help, multiple injuries | Child abuse; domestic violence; self-harm |
| Functional impact | Does the injury affect your daily life/work? | 「個傷口有冇影響你返工/日常生活？」 | Functional impact is a biopsychosocial problem | Unable to work; unable to care for self/children |
| Cosmetic concern | Are you worried about scarring? | 「你擔唔擔心留疤？」 | Links to ICE and hidden agenda | Plastic and reconstructive surgery referral [8] |
Case Report Form Answer Builder
- CC: "Skin injury to [site] for [duration]" — use patient's own words
- HPI high-yield points:
- Mechanism of injury (sharp/blunt/crush/bite/burn) [2]
- Timing (when, how long ago)
- Location, size, depth
- Bleeding amount, current haemostasis status
- Contamination, foreign body possibility
- Neurovascular status distal to wound
- Tetanus immunisation status
- Current symptoms: pain, swelling, signs of infection
- Any prior self-treatment
- Examples: "Wound management and closure," "Concern about infection," "Worried about scarring," "Pain and unable to work," "Need tetanus shot"
- How to phrase: State the single most important reason the patient came TODAY — often it is the concern/expectation, not just the wound itself.
| Example Wording | |
|---|---|
| Ideas | "I think I might need stitches" / "I'm worried it might be infected" |
| Concerns | "I'm afraid of permanent scarring" / "Worried about tetanus" / "Scared it won't heal because I have diabetes" |
| Expectations | "I want the wound cleaned and closed properly" / "I want a referral to a plastic surgeon" / "I need a sick leave certificate for work" |
- Traumatic laceration (or abrasion/contusion depending on mechanism)
- Minimum supporting evidence: history of sharp/blunt trauma → breach of skin integrity → wound of stated size/depth at stated location → no deep structure involvement on examination
| DDx | One Key Discriminator |
|---|---|
| 1. Wound infection / infected wound | Erythema, warmth, purulent discharge, fever — especially if delayed presentation |
| 2. Tendon / nerve injury | Loss of specific motor function or sensation distal to wound (e.g., cannot flex DIP = FDP injury) [5] |
| 3. Non-accidental injury | Inconsistent history, unusual injury pattern, multiple injuries at different stages [1] |
| Domain | Problem |
|---|---|
| Biological | Risk of wound infection / impaired healing (especially if diabetic or immunosuppressed) |
| Psychological | Anxiety about scarring / cosmetic outcome; fear of needles/procedures; PTSD if assault/accident |
| Social | Unable to work (especially manual labourer) → financial impact; childcare difficulty if dominant hand injured; if NAI → safeguarding concern |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Traumatic laceration (most likely) | Clean-cut wound with visible depth, bleeding edges, intact deep structures | Direct inspection of wound after cleaning; assess wound edges (sharp = laceration, irregular = tear/crush) | Confirms mechanical skin breach consistent with reported mechanism [4] |
| Wound infection | Surrounding erythema, warmth, tenderness, purulent discharge | Inspect wound margins; palpate for fluctuance; note discharge character | Signs of infection indicate secondary bacterial wound infection |
| Tendon injury | Loss of active movement at specific joint | Test each tendon individually: e.g., FDS — hold other fingers in extension, ask to flex PIP; FDP — hold PIP, ask to flex DIP [5] | Loss of isolated joint movement = tendon discontinuity |
| Nerve injury | Loss of sensation in specific nerve territory | Light touch and two-point discrimination in median/ulnar/radial nerve territories | Sensory deficit in defined territory confirms nerve transection [2] |
| Non-accidental injury | Multiple bruises/injuries at different stages of healing; patterned injuries | Full skin survey; look for injuries inconsistent with stated mechanism | Multiple-stage injuries suggest repeated trauma [1] |
| Open fracture | Bone visible in wound; bony crepitus; deformity | Inspection of wound base; gentle palpation of underlying bone | Visible bone or crepitus = open fracture requiring urgent orthopaedic referral [9] |
Exam Discriminators and Traps
Must Not Miss Red Flags — Urgent Referral
- Pulsatile / uncontrolled bleeding → vascular injury → apply direct pressure, urgent surgical referral
- Loss of distal motor/sensory function → nerve/tendon injury → urgent hand surgery / ortho referral [2][5]
- Visible bone / joint penetration → open fracture → IV antibiotics + urgent orthopaedic referral [9]
- Disproportionate pain + systemic toxicity + dishwater pus → necrotising fasciitis → emergency surgical debridement [10]
- Inconsistent history in a child → non-accidental injury → safeguarding protocol, do NOT discharge before senior review [1]
- Human/animal bite to hand → high infection risk (Pasteurella, Eikenella) → prophylactic antibiotics + close follow-up
- Forgetting to ask about tetanus immunisation — a very common exam omission.
- Not testing tendon function individually — especially flexor tendons in hand lacerations; FDS and FDP must be tested separately. [5]
- Missing a retained foreign body — always ask and consider X-ray (glass is radio-opaque!).
- Not screening for NAI when the history doesn't fit — especially in children or vulnerable adults. [1]
- Forgetting ICE / hidden agenda — the patient may not care about the wound itself but about scarring, compensation, or fear of an underlying condition.
- Not performing safety-netting at closing — must warn about infection signs (redness, swelling, pus, fever, red streaks) and when to return.
- Confusing wound terminology: excoriation = exogenous injury to epidermis; erosion = partial loss of epidermis; ulcer = full-thickness loss extending to dermis/subcutis [4][11].
- Clean wound < 6 hrs: irrigate, debride, primary closure ± tetanus prophylaxis
- Contaminated / > 6–8 hrs: irrigate, debride, consider delayed primary closure, tetanus +/- antibiotics
- Wound healing phases: haemostasis → inflammation → proliferation → remodelling [4]
- Safety-net: 「如果傷口越嚟越紅、腫、痛、有膿、或者發燒，要即刻返嚟。」
Key GC lecture point: Classification of injuries — clean vs contaminated; sharp (incised) vs blunt (laceration with ragged edges) vs crush vs penetrating vs bite — determines wound management approach [2][4].
Key GC lecture point: Wound infection and antiseptic technique — wound irrigation is the single most important step in reducing wound infection [4].
Key GC lecture point: Common hand injuries — always test individual tendon function; mallet finger (extensor tendon avulsion at DIP), jersey finger (FDP avulsion), and gamekeeper's thumb (UCL injury) are commonly tested [5].
Key GC lecture point: From GC 190 Burns — assess burn depth (superficial/partial/full thickness), TBSA (rule of nines), and need for fluid resuscitation [12].
High Yield Summary
What to ASK: Mechanism, timing, contamination, FB, neurovascular status, tendon function, tetanus status, PMH (DM), medications (anticoagulants), ICE, and screen for NAI/self-harm/domestic violence if history is inconsistent.
What to WRITE: CC in patient's words with mechanism and timing → HPI covering wound details and functional status → RFC (often concern-driven, e.g., "worried about scarring") → ICE → Most likely Dx = traumatic laceration → DDx: wound infection, tendon/nerve injury, NAI → Biopsychosocial: infection/healing risk, anxiety/scarring concern, work/functional impact → Physical sign: wound inspection + tendon testing.
What NOT to MISS: Tendon/nerve/vascular injury (test individually!), retained FB (XR if suspicious), tetanus status, NAI in children, necrotising fasciitis red flags, and safety-net advice at closing.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Adrian Lui Pediatrics Notes.pdf (p. 492 — Child Abuse / Non-accidental injuries) [2] GC lecture slides: GC 182. Chopped and stabbed wound in gang fight Nerves and vascular injury; Classification of injuries.pdf [3] Senior notes: Ryan Ho Neurology.pdf (p. 200 — Scalp and Skull Injury) [4] GC lecture slides: GC 178. An ugly wound Wound healing; Wound infection; Anti-septic technique.pdf [5] GC lecture slides: GC 233. Common Hand Injuries.pdf [6] Senior notes: Ryan Ho Endocrine.pdf (p. 98 — Diabetic Foot) [7] Senior notes: Block A - Dermatology PBL 1.pdf (p. 11 — Chlorhexidine contact dermatitis) [8] GC lecture slides: GC 192. I want to look better Plastic and reconstructive surgery.pdf [9] GC lecture slides: GC 231. High Energy Trauma Open Fracture_Part 2.pdf [10] GC lecture slides: GC 237. Musculoskeletal infection [Updated in 2025].pdf (p. 41 — Necrotising fasciitis clinical diagnosis) [11] Medicine lecture slides: Derm General Clerkship 2026 Part1.pdf (p. 4 — Types of secondary lesions) [12] GC lecture slides: GC 190. I have a scald Burn.pdf
Shoulder Pain
Shoulder pain is a common musculoskeletal complaint arising from disorders of the rotator cuff, glenohumeral or acromioclavicular joints, bursa, or referred sources such as cervical spine or visceral pathology.
Skin Itch (pruritus)
Pruritus is an unpleasant cutaneous sensation that provokes the desire to scratch, arising from dermatological, systemic, neurogenic, or psychogenic causes.