- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
734 Section III / Subspecialty Surgery
What are the blood prolactin levels with a prolactinoma?
Medical treatment of a prolactinoma?
Surgical treatment for a prolactinoma?
What is the treatment of a recurrent prolactinoma after surgical resection?
300 mg/L is diagnostic for prolactinoma ( 100 mg/L is abnormal)
Bromocriptine
Transsphenoidal resection of the pituitary tumor (in cases refractory to bromocriptine)
Radiation therapy
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What are the usual causes?
Most cases are due to trauma; of nontraumatic SAH, the leading cause is ruptured berry aneurysm, followed by arteriovenous malformations
What is a berry aneurysm?
What is the usual location of a berry aneurysm?
What medical disease increases the risk of berry aneurysms?
What is an Arterio-Venous Malformation (AVM)?
Where do they occur?
What are the signs/ symptoms of SAH?
Saccular outpouching of vessels in the circle of Willis, usually at bifurcations
Anterior communicating artery is #1 (30%), followed by posterior communicating artery and middle cerebral artery
Polycystic kidney disease and connective tissue disorders (e.g., Marfan’s syndrome)
Congenital abnormality of the vasculature with connections between the arterial and venous circulations without interposed capillary network
75% are supratentorial
Classic symptom is “the worst headache of my life”; meningismus is documented by neck pain and positive Kernig’s and Brudzinski’s signs; occasionally LOC, vomiting, nausea, photophobia
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Chapter 75 / Neurosurgery 735 |
What comprises the workup |
If SAH is suspected, head CT should |
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of SAH? |
be the first test ordered to look for |
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subarachnoid blood; LP may show |
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xanthochromic CSF, but is not necessary |
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if CT scan is definitive; this test should |
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be followed by arteriogram to look for |
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aneurysms or AVMs |
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What are the possible |
1. |
Brain edema leading to increased ICP |
complications of SAH? |
2. |
Rebleeding (most common in the first |
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24 to 48 hours posthemorrhage) |
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3. |
Vasospasm (most common cause of |
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morbidity and mortality) |
What is the treatment for vasospasm?
What is the treatment of aneurysms?
Nimodipine (calcium channel blocker)
Surgical treatment by placing a metal clip on the aneurysm is the mainstay of therapy; alternatives include balloon occlusion or coil embolization
What is the treatment of |
Many are on the brain surface and |
AVMs? |
accessible operatively; preoperative |
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embolization can reduce the size of the |
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AVM; for surgically inaccessible lesions, |
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radiosurgery (gamma knife) has been |
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effective in treating AVMs 3 cm in |
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diameter |
INTRACEREBRAL HEMORRHAGE |
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What is it? |
Bleeding into the brain parenchyma |
What is the etiology? |
#1 is hypertensive/atherosclerotic disease |
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giving rise to Charcot-Bouchard |
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aneurysms (small tubular aneurysms |
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along smaller terminal arteries); other |
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causes include coagulopathies, AVMs, |
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amyloid angiopathy, bleeding into a |
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tumor, and trauma |
Where does it occur? |
66% occur in the basal ganglia; putamen |
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is the structure most commonly affected |
736 Section III / Subspecialty Surgery |
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How often does blood |
66% of cases |
spread to the ventricular |
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system? |
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What is the usual |
66% present with coma; large |
presentation? |
putamen bleeding classically presents |
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with contralateral hemiplegia and |
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hemisensory deficits, lateral gaze |
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preference, aphasia, and homonymous |
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hemianopsia |
What is the associated |
CT scan |
diagnostic study? |
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What are the surgical |
CN III palsy, progressive alteration of |
indications? |
consciousness |
What is the prognosis? |
Poor, especially with ventricular or |
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diencephalons involvement |
SPINE |
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LUMBAR DISC HERNIATION |
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What is it? |
Extrusion of the inner portion of the |
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intervertebral disc (nucleus pulposus) |
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through the outer annulus fibrosis, |
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causing impingement on nerve roots |
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exiting the spinal canal |
Which nerve is affected? |
Nerve exiting at the level below (e.g., an |
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L4–L5 disc impinges on the L5 nerve |
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exiting between L5–S1) |
Who is affected? |
Middle-aged and older individuals |
What is the usual cause? |
Loss of elasticity of the posterior |
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longitudinal ligaments and annulus |
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fibrosis as a result of aging |
What are the most common |
L5–S1 (45%) |
sites? |
L4–L5 (40%) |
What is the usual presenting |
Low back pain |
symptom? |
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What are the signs:
L5–S1?
L4–L5?
L3–L4?
How is the diagnosis made?
What is the treatment?
Chapter 75 / Neurosurgery 737
Decreased ankle jerk reflex Weakness of plantar flexors in foot Pain in back/midgluteal region to
posterior calf to lateral foot Ipsilateral radiculopathy on straight leg
raise
Decreased biceps femoris reflex Weak extensors of foot
Decrease or absence of knee jerks, weakness of the quadriceps femoris, pain in lower back/buttock, pain in lateral thigh and anterior thigh
Pain in hip/groin region to posterolateral thigh, lateral leg, and medial toes
CT scan, CT myelogram, or MRI
Conservative—bed rest and analgesics Surgical—partial hemilaminectomy and
discectomy (removal of herniated disc)
What are the indications for |
1. Cauda equina syndrome |
emergent surgery? |
2. Progressive motor deficits |
What is cauda equina |
Herniated disc compressing multiple |
syndrome? |
S1, S2, S3, S4 nerve roots, resulting in |
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bowel/bladder incontinence, “saddle |
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anesthesia” over buttocks/perineum, low |
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back pain, sciatica |
What is “sciatica”? |
Radicular or nerve root pain |
CERVICAL DISC DISEASE |
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What is it? |
Basically the same pathology as lumbar |
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disc herniation, except in the cervical |
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region; the disc impinges on the nerve |
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exiting the canal at the same level of the |
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disease (e.g., a C6–C7 disc impinges on |
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the C7 nerve root exiting at the C6–C7 |
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foramen) |
738 Section III / Subspecialty Surgery |
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What are the most common |
C6–C7 (70%) |
sites? |
C5–C6 (20%) |
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C7–T1 (10%) |
What are the signs/ |
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symptoms: |
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C7? |
Decreased triceps reflex/strength, |
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weakness of forearm extension |
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Pain from neck, through triceps and into |
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index and middle finger |
C6? |
Decreased biceps and brachioradialis |
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reflex |
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Weakness in forearm flexion |
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Pain in neck, radial forearm, and thumb |
C8?
How is the diagnosis made?
What is the treatment?
What are the symptoms of central cervical cord compression from disc fragments?
Weakness in intrinsic hand muscles, pain in fourth/fifth fingers
CT scan or MRI
Anterior or posterior discectomy with fusion PRN
Myelopathic syndrome with LMN signs at level of compression and UMN signs distally; e.g., C7 compression may cause bilateral loss of triceps reflex and bilateral hyperreflexia, clonus, and Babinski signs in lower extremities
What is Spurling’s sign? |
Reproduction of radicular pain by having |
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the patient turn his head to the affected |
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side and applying axial pressure to the |
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top of the head |
SPINAL EPIDURAL ABSCESS |
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What is the etiology? |
Hematogenous spread from skin infections |
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is most common; also, distant abscesses/ |
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infections, UTIs, postoperative infections, |
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spinal surgery, epidural anesthesia |
What is the commonly |
Diabetes mellitus |
associated medical condition? |
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