Answer the questions

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Here are detailed answers to all the questions visible in the image:

Question 2 - Resistant Hypertension (48-year-old woman)

Presentation recap: 48F, BP 168/102 on 3 maximal antihypertensive medications, abdominal bruit over right upper quadrant, creatinine 1.5 mg/dL (elevated from baseline 1.0), K+ 3.2 mmol/L (low-normal).

1. Most Likely Cause of Hypertension

Renovascular Hypertension due to Renal Artery Stenosis (RAS)

The combination of:

Resistant hypertension (failing 3 drugs at max doses) - a classic red flag
Abdominal bruit (right upper quadrant - over the renal artery)
Rising creatinine from baseline
Hypokalemia (from secondary aldosteronism)

...points strongly to RAS. The most common etiology in this age group is atherosclerotic renal artery stenosis (ARAS). Fibromuscular dysplasia (FMD) typically affects younger women (<35 years), though it remains a differential. The mechanism is renal ischemia → renin release → angiotensin II → aldosterone → hypertension + potassium wasting.

2. Next Best Diagnostic Test

Renal artery duplex Doppler ultrasound (non-invasive, no contrast, no radiation) is the first-line imaging test. It assesses velocity ratios and identifies >60% stenosis.

Alternatives include:

CT angiography (CTA) or MR angiography (MRA) - highly accurate but involve contrast/gadolinium
Captopril nuclear renography - less used now
Renal angiography - gold standard, but invasive; reserved for when revascularization is planned

3. Mainstay of Treatment

Medical therapy is the primary approach: ACE inhibitors or ARBs + statins + aspirin + lifestyle modification (smoking cessation, diabetes control)
Note: ACE inhibitors/ARBs may cause a rise in creatinine in bilateral RAS - must monitor closely
Percutaneous transluminal renal angioplasty (PTRA) ± stenting is considered in selected patients (bilateral hemodynamically significant RAS, refractory hypertension, flash pulmonary edema, progressive CKD, unstable angina) - though RCTs have not shown stenting to be superior to medical therapy for most endpoints

Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.

Question 3 - Burn Injury (15-year-old boy, lesion shown)

The image shows a burn wound on the dorsum of the hand.

1. Identify the Lesion

This is a burn injury - appearing to be a partial-thickness (deep dermal) burn based on the appearance of skin breakdown on the hand.

2. Wallace Rule of 9

The Wallace Rule of Nines divides the body surface area (BSA) into units that are multiples of 9%:

Body Region	% TBSA (Adult)
Head and neck	9%
Each upper limb	9% (x2 = 18%)
Anterior trunk	18%
Posterior trunk + buttocks	18%
Each lower limb	18% (x2 = 36%)
Genitalia	1%
Total	100%

Important for this 15-year-old: The Rule of Nines is valid for patients above ~15 years of age. In younger children, the head is proportionally larger and the legs are smaller - hence a modified chart must be used.

3. Formula to Calculate Fluid

Parkland Formula (Baxter Formula):

Total fluid in first 24h = 4 mL × body weight (kg) × % TBSA burned

Give first half in the first 8 hours (from time of injury, not time of arrival)
Give second half over the next 16 hours

Example: 50 kg child with 20% burns = 4 × 50 × 20 = 4,000 mL in 24 hours → 2,000 mL in first 8h, 2,000 mL in next 16h.

4. Fluid of Choice

Lactated Ringer's solution (Hartmann's solution) - an isotonic crystalloid. It most closely approximates the electrolyte composition of plasma and is the standard fluid for burn resuscitation in the first 24 hours.

5. Best Chart for Assessment of Burn Injury

Lund and Browder Chart - this is the most accurate and preferred method, especially for:

Children (accounts for age-related proportional differences)
Larger or complex burns
Serial documentation throughout admission

It subdivides body regions further than the Rule of Nines and differentiates burn depth by shading. Developed in 1942, it remains the gold standard at burns units.

Bailey & Love's Short Practice of Surgery, 28th Ed.

Tintinalli's Emergency Medicine, p. 598-611

Question 4 - Health System Model (Country E)

Description: Community cooperatives, residents pay small fees to a pooled fund, locally recruited health workers, focus on prevention and primary care.

Identify the Health System Model

This describes the Bismarck Model (social insurance/contributory model) - specifically a community-level variant. More precisely for this scenario, it most closely resembles the Community Health Insurance / Social Health Insurance model, where:

Citizens contribute small, pooled fees (not tax-funded like Beveridge; not out-of-pocket like market model)
Services are locally organized and community-managed
Emphasis on primary care and prevention

Benefits:

Universal or near-universal coverage within the community
Financial risk pooling across members
Community ownership increases accountability and local engagement
Focus on preventive care reduces costly tertiary interventions
Health workers are familiar with local culture and language

Limitations:

Small pool size = limited financial capacity for catastrophic illness
Cross-subsidization may be insufficient for very poor communities
Depends on community willingness and consistency of contribution
Limited scope for specialist care or high-tech interventions
Risk of fragmentation between schemes (inequity between different cooperatives)

Question 5 - Post-Abortion Complication (Nulliparous woman, day 2 after medical abortion)

Presentation: Fever 39°C, single chill, malaise, tachycardia, pallor, leukocytosis (10.0 G/L), ESR 35 mm/h, tender/soft abdomen above pubis, uterus slightly enlarged, soft, mobile, moderately painful, pharynx closed, bloody odorless lochia.

Diagnosis: Acute Endometritis (post-abortion endometritis)

This is the most likely complication. The uterus is the source of infection (enlarged, tender), with systemic signs of infection (fever, tachycardia, leukocytosis) and normal abdominal exam excluding peritonitis.

I. Complication: Answer = 4. Acute endometritis
- Parameter (1) and Appendicitis (2) are ruled out by abdominal softness and uterine source
- Pelvioperitonitis (3) would show peritoneal signs (rigid abdomen, rebound tenderness) - absent here
- Acute endometritis (4) fits perfectly: post-abortion, soft uterus, fever, tender on bimanual, closed cervix, odorless lochia

II. Leading Role in Treatment: Answer = 4. Antibiotics

Post-abortion endometritis requires broad-spectrum antibiotics as the cornerstone of treatment. Typical regimens include:

Doxycycline + metronidazole (outpatient)
IV clindamycin + gentamicin (inpatient/severe cases)
Uterotonic drugs (2) play a secondary supportive role to promote uterine drainage
NSAIDs (1) and antipyretics (3) are adjunctive only

III. Long-term Consequences: All of the above can occur

1. Infertility - from tubal scarring/adhesions (most significant long-term risk)
2. Chronic pelvic pain - from pelvic adhesions
3. Incompetence (cervical incompetence) - can result from instrumentation/infection
4. Dysmenorrhea - from intrauterine adhesions (Asherman syndrome) or endometrial damage

Tintinalli's Emergency Medicine, Induced Abortion section

Pfenninger & Fowler's Procedures for Primary Care, 3rd Ed.

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