…because of the cosmesis, often with antibiotic prophylaxis. Deep puncture wounds , where the base cannot be inspected or irrigated clean. Wounds with retained foreign material…

…is decided before the needle goes in: the choice of site, the use of ultrasound throughout the puncture, and maintaining maximal barrier precautions without shortcuts…

…complete heart block without current symptoms, alternating bundle branch block in acute anterior infarction, and before drugs or procedures with a known risk of bradycardia…

…bacterial CNS infections states that CT must not be performed before lumbar puncture in suspected bacterial meningitis — not even with a reduced level of consciousness…

…the risk of pneumothorax and is now the standard — puncture on the basis of percussion and a chest radiograph alone belongs to an earlier era…

…the puncture went. Indications Unexplained cytopenia in one or more cell lines. Suspected acute leukaemia, myelodysplastic syndrome or myeloproliferative neoplasm. Work up and staging of…

…disease. Contraindications Infection of the skin or soft tissues over the puncture site — use another approach or refrain. Bacteraemia without suspicion of joint infection (relative…

…first. Procedure Choice of insertion site The left lower quadrant is the first choice : the abdominal wall is thinner there than on the right, and…

…the puncture site. An arm with an arteriovenous fistula, previous axillary clearance or lymphoedema. A limb with paresis or marked swelling. A vein suspected of…

…a small amount of lidocaine without adrenaline (epinephrine). 3. Puncture 1–2 cm proximal to the wrist crease at an angle of 30–45 degrees…

…not exclude Diastolic collapse of the right atrium and right ventricle The cardinal echocardiographic finding A dilated inferior vena cava without respiratory variation Strongly suggests…

…septic shock, or a need for high dependency or intensive care 3 Take at least two sets of blood cultures from separate peripheral punctures. Also…

Procedurer The value of the exercise test lies not in ST depression alone but in the overall picture : exercise capacity, symptoms, blood pressure response, heart…

…the clinical picture, medication, fluid balance, renal function, electrolytes and supplemental oxygen [1]. Distinguish between: Acidaemia and alkalaemia , which describe the current pH of the…

… cellulitis instead gives a diffuse oedematous picture without a demarcated fluid collection. Ultrasound also shows the depth of the cavity and its distance to vessels…

…strong suspicion of another or an additional cause [1]. Delirium tremens most often begins after one to three days but can start earlier in patients…

…the ratio between the body's exchangeable sodium and potassium and the total body water. In hypotonic hyponatraemia the amount of water is too great…

…looking for right ventricular strain. If CT pulmonary angiography can be performed immediately, do it. Otherwise the echocardiographic findings plus the clinical picture are sufficient…

…interpretation of the Doppler signals. Figure 1. The image on the left shows many sample volumes within a Doppler sector. The picture on the right…

…initially in both arms if this can be done without losing time. 7. Perform urgent CT of the brain and CT angiography from the aortic…

…fluid and early contact with anaesthesia or intensive care Refractory anaphylaxis Persisting airway, respiratory or circulatory compromise despite two adequate intramuscular doses of adrenaline and…

…Subtype Typical picture Clinical significance : : : Hyperactive Agitation, motor restlessness, picking, calling out, irritability, hallucinations More easily detected, but accounts for a minority of cases Hypoactive…

…L pH < 7.00 or bicarbonate < 10 mmol/L Stupor or coma may occur Mixed picture of DKA and HHS Overlap is common…

…continuous ECG monitoring and early assessment of the need for dialysis ECG changes or serious neuromuscular symptoms mean a high risk even if the plasma…

…person without diabetes therefore does not normally need investigation on the basis of an isolated, asymptomatic low sensor reading alone. Symptoms Autonomic symptoms Early warning…

…The anatomy of the nail apparatus The terminology is hard to follow without a picture, and several of the steps below refer to structures that…

…have no recognized history of angina or MI, making the distinction from primary dilated cardiomyopathy particularly difficult. When present, the clinical picture may include: Symptoms…

…permitted when assessing dietary electrolyte intake, because it can increase blood pressure and may affect interpretation of the clinical picture. A 24 hour urine collection…