This page reveals the answer
Want to test yourself first? Play the original case before reading the clues and explanation below.
Five progressive clues
These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 38-year-old right-handed florist is referred to outpatient hand therapy five days after an emergency department visit. She is anxious to get back to arranging bouquets, but her chief complaint is a painful, oozing patch of skin across the back of her dominant hand and wrist that throbs constantly and keeps her up at night.
Clue 2
The injury happened suddenly at home; within minutes the skin reddened, and over the next day it formed tense, fluid-filled blisters. The raw area is intensely painful to light touch and even to moving air, yet she has had no fever, chills, or spreading redness. The pain has been constant since the exact moment of injury rather than building up gradually, and she takes no regular medications and has no history of skin disease.
Clue 3
On examination the wound is confined to a sharply demarcated zone matching where a splash landed on the dorsum of the hand. The base is moist and pink-red and briskly blanches with pressure, the blister roofs are thin-walled, and pinprick sensation within the wound is fully preserved and exquisitely tender. The surrounding skin is normal in color with no red streaking toward the elbow.
Clue 4
The emergency department chart notes the area was cooled under running water for 20 minutes on arrival and then dressed with silver sulfadiazine. Blister-fluid culture is negative, and her white cell count and C-reactive protein are both normal. There is no history of cold exposure and no new topical products, detergents, or jewelry.
Diagnosis
Burns
Why the diagnosis fits
A sharply demarcated, moist, pink-red wound that blanches with pressure, has thin-walled blisters, and preserves exquisitely painful pinprick sensation is a superficial partial-thickness thermal injury from the hot-liquid splash pattern. Normal WBC/CRP and a negative blister-fluid culture, plus the abrupt onset from the moment of injury, are the key discriminators from cellulitis, whose closest mimic is ruled out because infection is gradual, spreading, warm, and febrile with raised inflammatory markers and lymphangitic streaking. It is not frostbite (a cold injury that starts numb and hard with delayed demarcation) nor contact dermatitis (itchy, ill-defined, delayed). OT management centers on edema control, an anti-deformity intrinsic-plus orthosis, early active motion, and later silicone scar management to prevent dorsal-hand contracture.
Educational reference
The explanation and decisive case findings were checked against the source below.
Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.