CASE INFORMATION

Case ID: EMER-2025-006
Case Name: Daniel Carter
Age: 34 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S18 (Laceration/Cut)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.2 Elicits history and patient concerns 1.5 Provides clear aftercare instructions
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including mechanism of injury 2.3 Performs a focused wound examination 2.4 Identifies risk factors for wound infection and healing delay
3. Diagnosis, Decision-Making and Reasoning	3.2 Determines wound complexity (superficial vs deep) 3.4 Identifies need for advanced closure or specialist referral
4. Clinical Management and Therapeutic Reasoning	4.1 Provides appropriate wound care and closure technique 4.3 Prescribes appropriate prophylactic antibiotics if indicated 4.5 Considers tetanus vaccination status
5. Preventive and Population Health	5.1 Discusses wound care and infection prevention strategies
6. Professionalism	6.2 Ensures patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Completes relevant documentation (e.g., WorkCover, medical certificate)
8. Procedural Skills	8.1 Demonstrates appropriate wound closure technique (suturing, steri-strips, glue)
9. Managing Uncertainty	9.1 Recognises wounds requiring referral to plastics or hand surgery
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies signs of wound complications (infection, foreign body, neurovascular injury)

CASE FEATURES

Young male presents with a deep laceration to his left forearm sustained while working with glass.
Reports bleeding, pain, and difficulty moving fingers but denies major numbness.
Works as a chef, concerned about infection and return to work.
Requires assessment for tendon/nerve injury, wound closure decision, and tetanus prophylaxis.
Discussion around wound care, infection prevention, and follow-up.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Carter
Age: 34 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Nil regular medications

Past History

No previous significant injuries
Up to date with tetanus vaccination (last dose 6 years ago)

Social History

Works as a chef, frequent use of hands
Right-hand dominant
Non-smoker, consumes alcohol socially

Family History

No significant family history

Smoking

Non-smoker

Alcohol

Social drinker, 3-4 drinks per week

SCENARIO

Daniel, a 34-year-old chef, presents with a 4 cm deep laceration on his left forearm after accidentally breaking a glass while washing dishes. He reports bleeding that has now slowed, moderate pain, and some difficulty moving his fingers, but denies major numbness or weakness.

He is worried about infection and when he can return to work, as his job involves extensive manual dexterity and handling food.

EXAMINATION FINDINGS

General Appearance: Well, alert, no distress.
Wound Examination:

Location: Left volar forearm, 4 cm in length, deep but clean edges.
Bleeding: Controlled with direct pressure.
Depth: Extends into subcutaneous tissue but muscle appears intact.
Foreign body: No visible glass fragments, but mechanism suggests possible risk.

Neurovascular Examination:

Capillary refill <2 sec, radial pulse intact.
Sensation intact over all fingers.
Motor function:
- Full wrist flexion and extension.
- Mild difficulty with thumb opposition (concern for flexor tendon injury).

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to assess Daniel’s injury?

Prompt: Ask about timing, mechanism, and contamination risk (glass, metal, soil, animal bite).
Prompt: Assess for signs of deeper injury (numbness, weakness, bleeding concerns).

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Discuss likelihood of superficial vs deep laceration, tendon involvement, and foreign body risk.
Prompt: Explain why a flexor tendon injury must be ruled out.

Q3. What is the initial management plan for Daniel?

Prompt: Discuss wound cleaning, closure options (sutures, steri-strips, glue), and tetanus prophylaxis.
Prompt: Identify when to refer for specialist repair (e.g., suspected tendon injury).

Q4. What are the key complications to monitor, and how would you prevent them?

Prompt: Explain the risk of wound infection, scarring, and tendon adhesion.
Prompt: Identify signs requiring urgent review (infection, impaired movement, wound dehiscence).

Q5. How would you counsel Daniel on wound care, return to work, and follow-up?

Prompt: Provide instructions for wound care (cleaning, dressing changes, signs of infection).
Prompt: Discuss when he can safely return to work based on healing and function.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to assess Daniel’s injury?

A thorough history is essential to determine wound complexity, risk of complications, and appropriate management.

1. Mechanism of Injury

What object caused the laceration? (e.g., sharp glass vs blunt force)
Was the wound clean or contaminated with debris?
How much force was involved? (High-impact injuries increase risk of deeper damage)

2. Bleeding and Pain Assessment

Did bleeding stop with direct pressure?
Is there persistent oozing, suggesting arterial involvement?
Pain severity and response to analgesia?

3. Function and Sensory Changes

Any numbness or tingling? (Sensory nerve damage)
Any weakness or inability to move fingers? (Flexor tendon injury)
Any loss of grip strength?

4. Infection Risk and Tetanus Status

Time since injury? (>6 hours increases infection risk)
Signs of infection (redness, swelling, pus, fever)?
Tetanus vaccination status? (Last dose >5 years may require booster)

5. Work and Lifestyle Impact

Is the injury on the dominant hand?
Impact on work as a chef (manual dexterity, hygiene concerns)?

A structured history helps determine wound severity, infection risk, and appropriate treatment pathway.

Q2: What are the most likely diagnoses, and what features support your conclusion?

1. Superficial Forearm Laceration (Most Likely)

Clean-edged wound suggests a sharp object injury.
No exposed tendon or bone, indicating a superficial depth.
Bleeding controlled with pressure, reducing concern for arterial involvement.

2. Possible Flexor Tendon Injury

Difficulty with thumb opposition raises concern for partial flexor tendon involvement.
Requires thorough motor testing before ruling out tendon damage.

3. Foreign Body Retention

Mechanism (glass injury) increases risk of embedded fragments.
Wound exploration or imaging (X-ray/ultrasound) may be required.

Differential Diagnoses

Deep muscle laceration: If active movement is painful or restricted.
Neurovascular injury: If numbness or poor capillary refill is present.

Accurate diagnosis ensures correct wound closure technique and avoids missed complications.

Q3: What is the initial management plan for Daniel?

1. Wound Cleansing and Assessment

Irrigate with normal saline to remove debris.
Explore for tendon damage, foreign bodies, and depth assessment.

2. Wound Closure Options

Suturing recommended for deeper lacerations (>5 mm deep or gaping).
Steri-strips or glue if superficial and well-approximated.
Leave open if high-risk (infected, contaminated, deep puncture).

3. Pain and Infection Control

Paracetamol ± NSAIDs for pain relief.
Antibiotics only if infection risk is high (e.g., contaminated wound).

4. Tetanus Prophylaxis

If last tetanus dose was >5 years ago, booster recommended.

5. Work and Follow-Up Advice

Light duties recommended for 1-2 weeks.
Review in 48 hours for signs of infection or healing issues.

Providing appropriate wound care reduces infection risk and promotes optimal healing.

Q4: What are the key complications to monitor, and how would you prevent them?

1. Wound Infection

Signs: Increased redness, swelling, pus, pain, fever.
Prevention: Proper cleansing, avoiding unnecessary sutures in contaminated wounds.

2. Flexor Tendon Rupture

Signs: Increasing difficulty moving fingers post-repair.
Prevention: Ensure thorough examination before closure.

3. Scar Formation and Adhesion

Risk: Poor wound healing leading to restricted movement.
Prevention: Early mobilisation and scar massage post-healing.

4. Foreign Body Retention

Signs: Persistent pain, delayed healing.
Prevention: Imaging if suspicion remains after exploration.

Monitoring ensures early detection and intervention if complications arise.

Q5: How would you counsel Daniel on wound care, return to work, and follow-up?

1. Wound Care Instructions

Keep the wound clean and dry for 48 hours.
Change dressings daily and watch for infection signs.

2. Activity and Work Modifications

Avoid heavy lifting or repetitive hand movements for 1-2 weeks.
Use protective dressing at work to prevent contamination.

3. Signs Requiring Urgent Review

Worsening redness, swelling, pus, or fever.
Difficulty moving fingers or worsening pain.

4. Follow-Up Plan

Review in 48 hours for infection and healing assessment.
Suture removal in 7-10 days.

Clear aftercare guidance ensures proper healing and safe return to work.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, assessing mechanism, contamination risk, function, and infection signs.
Accurate diagnosis, distinguishing superficial vs deep laceration, tendon injury, and foreign body retention.
Appropriate wound management, including cleansing, closure choice, and tetanus prophylaxis.
Recognition of complications, such as infection, tendon rupture, and foreign body retention.
Patient-centred counselling, addressing wound care, work impact, and follow-up needs.

PITFALLS

Failing to assess tendon function thoroughly, leading to missed tendon injury.
Overlooking foreign body risk, especially with glass-related injuries.
Inappropriate closure technique, increasing infection risk in contaminated wounds.
Neglecting tetanus prophylaxis, particularly if vaccination status is unclear.
Providing unclear return-to-work advice, causing unnecessary work absence or re-injury.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD