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Toronto Notes is a concise and comprehensive medical review revised annually by the University of Toronto student contributors under the guidance of the Faculty of Medicine. This reference text started as a compilation of notes written by and shared among University of Toronto students to study for their medical licensing exams. After 34 years, it has become the most reputable study guide used by medical students across Canada and around the world.

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Toronto Notes 2020 Contributors

Editors-in-Chief
Megan Drupals
Matthaeus Ware

Production Managers
Yuliya Lytvyn
Maleeha A. Qazi

Clinical Handbook Editors
Kirusanthy Kaneshwaran
Amirpouyan Namavarian
Healey Shulman

Communications Managers
Courtney Francis
David Lee

Online Content Managers
Yuri Chaban
Tiange Li
Yasser Salama
Harris Sheikh

EMN Content Reviewers
Joel George
Fadi Gorgi
Happy Inibhunu
Harsh Parikh
Darian Perruzza

BMC Production Editors
Farah Hamade
Jennifer Shao

CONTENT REVIEW COMMITTEE

Steven (Sung Min) Cho
Rebecca Crawford
Sarah Saba Khan
David Lee
Amita Mall
Andrew Mazzanti
Kristian McCarthy
Gagandeep Singh
Linlei Ye
And ELOM and PHPM Chapter Editors

BMC ILLUSTRATORS

Ingrid Barany
Brittany Cheung
Eric Chung
Jennifer Gu
Katrina Hass
Cassie Hillock-Watling
Taeah Kim
Jennifer Lee
Chloe Ng
Ariadna Pomada Villalbi
Colleen Paris
Yu Xiang Ren
Ava Schroedl
Christine Shan
Lesia Szyca
Emily Taylor
Willow Yang
Roxanne Ziman

PRIMARY

Associate Editors
Vanessa Sheng
Kimberly Young

EBM Editors
Hanna Jalali
Emily Kornelsen

MEDICINE

Associate Editors
Sonieya Nagarajah
Wid Yaseen

EBM Editors
Robert D'Cruz
Roslyn Mainland

SURGERY

Associate Editors
Amrit Sampalli
Ryan Wang

EBM Editors
Akshdeep Bhatia
Natalie Landon-Brace

Chapter Editors

Ethical, Legal, and Organizational Medicine
Zainab Doleeb
Moiz Mikail
Jennifer Zheng

Anesthesia and Perioperative Medicine
Dong An
Sylvie Bowden
Isabelle Laksono
Ryan Ramos

Clinical Pharmacology
Sarfraz Gill
Cathy Huilin Lu
Sheza Qayyum

Dermatology
Na-Young Cindy Kang
Matthew Ladda
Khalad Maliyar

Emergency Medicine
Kiran Grant
Arshia Pedram Javidan
Jason CS Kwan
Natalie Paolucci

Family Medicine
Bryce Chen
Ingrid Cheung
Tiffany Got
Monica Shah

Medical Genetics
Andrew Assatory
Kelly Dong

Medical Imaging
Chaitanya Bhatt
Keshav Narang
Taryn Rohringer

Pediatrics
Kristen Dietrich
Brian Earl
Taaha Muhammad
Jacqui van Warmerdam

Palliative Medicine
Airiss Chan
Kristen Dietrich
Kiran Grant
Verina Hanna
Valerie Kim
Sheida Naderi-Azad
Monica Shah
Donald Wang

Psychiatry
Ayan Dey
Meera Mahendiran
Fiona Moloney

Public Health and Preventive Medicine
Zainab Doleeb
Stephanie Hosang
Chantal Phillips

Cardiology and Cardiac Surgery
David Bobrowski
Sagar Patel
Amr Saleh
Klaudiusz Stoklosa

Endocrinology
Armin Farahvash
Ghazal Haddad
Alice Zhu

Gastroenterology
Christina Blagojevic
Airiss Chan
Jennifer Zheng

Geriatric Medicine
Emily Chen
Kimberley Lau
David Wiercigroch

Hematology
Zachary Blatman
Sara Mirali
Natalya O'Neill

Infectious Diseases
Monisha Basu
Michelle Lee
Sabrina Yeung

Nephrology
Karan Chohan
Savar Kaul
Aneesh Thakore

Neurology
Laavanya Dharmakulaseelan
Megan Hird
Jenny Liao

Respirology
Krish Bilimoria
Reza Fakhraei
Ortenc Hoxha

Rheumatology
Onella Charles
Nathalie Loeb
Cameron Taheri

General Surgery and Thoracic Surgery
Melanie Elhafid
Sina Hadipour-Lakmehsari
Darby Little
Andreea Matei

Gynecology
Isabella Fan
Lyn (Xinglin) Li
Melissa Tigert
Eliya (Zi Ying) Zhao

Neurosurgery
Sara Ahmed
Anders Erickson
Sydney McQueen

Obstetrics
Susan Dong
Julia Hollingsworth
Abirami Kirubarajan

Ophthalmology
Yusuf Ahmed
Avi Garg
Prem Nichani
Bryan Wong

Orthopedics
Sofia Solar Cafaggi
Anser Daud
Emmanuel Igbokwe
Geoffrey Schemitsch

Otolaryngology
YiQin Cheng
Christopher End
Christina (Joo Hyun) Kim
Gianluca Sampieri

Plastic Surgery
Shawn Khan
Mithila Somasundaram
Janakan Somasundaram

Urology
Adam Bobrowski
Christina Ding

Vascular Surgery
Shane Natalwalla
Lyon Qiao

Copy Editors

Ethical, Legal, and Organizational Medicine
Dakoda Herman
Iris Kim
Stephanie Schwindt
Katie Wilkins

Anesthesia and Perioperative Medicine
Linor Berezin
Clemence Cote
Emanuel Mastrangelo

Clinical Pharmacology
Monish Ahluwalia
Kathak Vachhani

Dermatology
Maria Leis
Seiwon Park
Ashmita Singh
Evan Tang

Emergency Medicine
Danielle Lewis
Ming K. Li
Kenneth Williams
Hanyan Zou

Family Medicine
Stephanie Hosang
Brendan Kelly
Danny Ma
Lauren Wintraub

Medical Genetics
Nicholas Light
Joanna Yang

Medical Imaging
Thomas Chang
Sabrina Fitzgerald
Mana Modares

Pediatrics
Yousuf Ahmed
Anna Jiang
Benjamin Martinez
Ananya Srivastava

Palliative Medicine
Maleeha A. Qazi
Grace Xu

Psychiatry
Ruth Chau
Jeanette Hui
Jackie Tsang
Mary Xie

Public Health and Preventive Medicine
Mallory Jackman
Andrew Terence Lam
Max Solish
Mithila Somasundaram

Cardiology and Cardiac Surgery
Ahmed Abdelaal
Nitish Dhingra
Steven Mejia
Clara Osei-Yeboah

Endocrinology
Monica Boctor
Irakli Dzneladze
Lindsey Hatcher
Christine Wu

Gastroenterology
Hifza Buhari
Kyung Young Kim
Alicia Serrano
Jack Su

Geriatric Medicine
Dorothy Qian
Charles Brian Serapio

Hematology
Justin Brunet
Reid Gallant
Rohit Jogendran
Yici (Andrea) Liu

Infectious Diseases
Arnav Agarwal
Kevin Jia Qi Chen
Andreea Damian
Adrian Witol

Nephrology
Peter Nakhla
Nawazish Naqvi

Neurology
Sabrina Campbell
Mythili Nair
Kaylee Sohng
Edwin Wong

Respirology
Emily DeHaas
Arjuna Maharaj
Nicholas Taylor

Rheumatology
Tao Chan
Dario Ferri
Deepanshu Sharma

General Surgery and Thoracic Surgery
Anisha Akhtar
Flora Jung
Shawn Khan
Ayesha Tasneem

Gynecology
Alessandra Ceccacci
Cara Elliott
Catherine Meng
Ronak Saluja

Neurosurgery
Dan Budiansky
Zaid Salaheen
Raza Syed
Hoyee Wan

Obstetrics
Zainab Doleeb
Justin Lim
Karly Stratos
Wei (Sheila) Yu

Ophthalmology
Yuri Chaban
Arjan Dhoot
Yuliya Lytvyn
Felicia Tai

Orthopedics
Robert Koucheki
Janakan Somasundaram
Jane Zhu

Otolaryngology
Arshia Eshtiaghi
Mark Khoury
Justin Lu

Plastic Surgery
Matthew Carr
Justin Haas
Golsa Shafa
Jessica Trac

Urology
Adree Khondker
Xinran Liu
Xin Xu

Vascular Surgery
Lina Elfaki
Raumil Patel

All contributing professors have been appointed at the University of Toronto.

PRIMARY

Ethical, Legal, and Organizational Medicine

Erika Abner, LLB, LLM, PhD
Faculty Lead, Ethics and Professionalism
Assistant Professor, Department of Family and Community Medicine
Undergraduate Medical Education

Andria Bianchi, PhD
University Health Network
Dalla Lana School of Public Health
University of Toronto

Chase Everett McMurren, BA, BEd, MD, CCFP
Department of Family and Community Medicine
University of Toronto

Jason J Pennington, MD, MSc, FRCSC
Division of General Surgery
Department of Surgery
Scarborough Health Network

Lisa Richardson, MD, MA, FRCPC
Division of General Internal Medicine
Department of Medicine
University Health Network

Anesthesia and Perioperative Medicine

Ahtsham Niazi, MBBS, FCARCSI, FRCPC
Department of Anesthesia and Pain Management
University Health Network

Anita Sarmah, MBChB, MD, FRCA, FRCPC
Department of Anaesthesia
Sunnybrook Health Sciences Centre
Programme Director, UME Anesthesia
University of Toronto

Diana Tamir, MD, FRCPC
Staff Anesthesiologist, Toronto General Hospital
Clinical Director of the Acute Pain Service
Postgrad Anesthesia Site Assistant Coordinator
Department of Anesthesia and Pain Management
Toronto General Hospital

Clinical Pharmacology

David Juurlink, BPhm, MD, PhD, FRCPC
Division of Clinical Pharmacology and Toxicology, Departments of Medicine and Paediatrics
Sunnybrook Health Sciences Centre

Cindy Woodland, PhD
Associate Professor, Teaching Stream
Director, Collaborative Specialization in Biomedical Toxicology
Director, Applied Clinical Pharmacology Program

Dermatology

David Adam, MD, FRCPC
Division of Dermatology, Department of Medicine
St. Michael’s Hospital

Patrick Fleming, MD, MSc, FRCPC, FAAD, FCDA
Assistant Professor, Division of Dermatology
Dermatologist, Lynde Institute for Dermatology
Investigator, Probity Medical Research

Marissa Joseph, MD, MScCH, FRCPC, FRCPC
Division of Dermatology, Department of Medicine
Women’s College Hospital and The Hospital for Sick Children

Jensen Yeung, MD, FRCPC
Division of Dermatology, Department of Medicine
Women’s College Hospital

Emergency Medicine

Mark Freedman, BSc, MD, FRCPC
Department of Emergency Medicine
Sunnybrook Health Sciences Centre

Nadia Primiani, MD, CCFP(EM)
Department of Emergency Medicine
Sinai Health System

Fernando Teixeira, MD, FRCPC
Department of Emergency Medicine
St. Michael’s Hospital

Family Medicine

Ruby Alvi, MD, CCFP, MHSc
Department of Family and Community Medicine

Chase Everett McMurren, BA, BEd, MD, CCFP
Department of Family and Community Medicine
University of Toronto

Azadeh Moaveni, MD, CCFP, FCFP
Department of Family and Community Medicine
University Health Network
Toronto Western Hospital

Medical Genetics

Hanna Faghfoury, MDCM, FRCPC, FCCMG
The Fred A Litwin Family Centre in Genetic Medicine, Department of Medicine
Mount Sinai Hospital and University Health Network

Graeme AM Nimmo, MBBS, MSc, FRCPC
The Fred A Litwin Family Centre in Genetic Medicine, Department of Medicine
Mount Sinai Hospital and University Health Network

Joyce So, MD, PhD, FRCPC, FCCMG
The Fred A Litwin Family Centre in Genetic Medicine, Department of Medicine
Mount Sinai Hospital and University Health Network

Medical Imaging

Nasir Jaffer, MD, FRCPC
Division of Abdominal Imaging, Department of Medical Imaging
Mount Sinai Hospital and University Health Network
Joint Department of Medical Imaging
University of Toronto

John Kavanagh, MD, FRCPC
Division of Cardiothoracic Imaging, Department of Medical Imaging
Joint Department of Medical Imaging
University of Toronto

Kieran Murphy, MB, FRCPC, FSIR
Interventional Neuroradiology,
Professor of Medical Imaging

Eugene Yu, MD, FRCPC
Division of Neuroradiology, Department of Medical Imaging
University Health Network

Paediatrics

Julie Johnstone, MD (FRCPC), MScCH
Division of Paediatric Medicine, Department of Paediatrics
The Hospital for Sick Children

Laila Premji, MD, FRCPC
Division of Paediatric Medicine, Department of Paediatrics
The Hospital for Sick Children

Angela Punnett MD FRCPC
Division of Haematology/Oncology, Department of Paediatrics
The Hospital for Sick Children

Shazeen Suleman, MSc, MD, MPH (FRCPC)
Women and Children's Health
St. Michael's Hospital
Unity Health Toronto

Palliative Medicine

Risa Bordman, MD, CCFP(PC), FCFP
Associate Professor
Faculty Development Program Lead, Office of Education Scholarship
Co-chair Education Committee, Division of Palliative Care
Department of Family & Community Medicine

Adam Rapoport, MD, FRCPC, MHSc
Departments of Paediatrics and Family & Community Medicine
University of Toronto
Paediatric Advanced Care Team, SickKids
Emily's House Children's Hospice

Donna Spaner, MD, CCFP(PC), FCFP, MScCH
Division of Palliative Care, Department of Family and Community Medicine
Toronto Grace Health Centre

Psychiatry

Saulo Castel, MD, PhD, FRCPC
Director, Inpatient Services
Sunnybrook Health Sciences Centre
Assistant Professor, Department of Psychiatry

Ellen Margolese, LLB, MD, FRCP(C)
Assistant Professor
Undergraduate Education Coordinator
Staff Psychiatrist​
Mount Sinai Hospital

Mary Preisman, MD, FRCPC
Department of Psychiatry
Mount Sinai Hospital

Public Health and Preventive Medicine

Chase Everett McMurren, BA, BEd, MD, CCFP
Department of Family and Community Medicine
University of Toronto

Onye Nnorom, MDCM, CCFP, MPH, FRCPC
Dalla Lana School of Public Health, University of Toronto
Department of Family and Community Medicine, University of Toronto

Jason J Pennington, MD, MSc, FRCSC
Division of General Surgery
Department of Surgery
Scarborough Health Network

Andrew Pinto, BSc, MD, CCFP, FRCPC, MSc
Department of Family and Community Medicine, St. Michael's Hospital
Department of Family and Community Medicine, University of Toronto
Dalla Lana School of Public Health, University of Toronto

Lisa Richardson, MD, MA, FRCPC
Division of General Internal Medicine
Department of Medicine
University Health Network

MEDICINE

Cardiology and Cardiac Surgery

Chi-Ming Chow, MD, CM, MSc, FRCPC
Division of Cardiology, Department of Medicine
St. Michael’s Hospital

Paul Dorian, MD, MSc, FRCPC
Division of Cardiology
St. Michael’s Hospital

Jacob A. Udell, MD, MPH, FRCPC
Division of Cardiology, Department of Medicine
Women's College Hospital and Toronto General Hospital
University of Toronto

Bobby Yanagawa, MD, PhD, FRCSC
Division of Cardiac Surgery
St Michael’s Hospital

Endocrinology

Karen Gomez-Hernandez, MD, MSc
Department of Endocrinology
University Health Network Mount Sinai Hospital

Geetha Mukerji, MD, MSc, FRCPC
Division of Endocrinology
Women’s College Hospital

Phillip Segal, MD, FRCPC
Division of Endocrinology
University Health Network

Gastroenterology

Maria Cino, BSc(Hon), MSc, MD, FRCPC, CAGF
Division of Gastroenterology
University Health Network, Toronto Western Division
Associate Professor, University of Toronto

Nicola L. Jones, MD, FRCPC, PhD
Department of Paediatrics
Division of Gastroenterology, Hepatology and Nutrition
The Hospital for Sick Children

Gabor Kandel, MD, FRCPC
Division of Gastroenterology, Department of Medicine
St. Michael’s Hospital

Piero Tartaro, MD, MScCH, FRCPC
Division of Gastroenterology, Department of Medicine
Sunnybrook Health Sciences Centre

Geriatric Medicine

Vicky Chau, MD, MScCH, FRCPC
Division of Geriatric Medicine, Department of Medicine
Sinai Health System

Karen D’Silva, MD, MS, FRCPC
Division of Geriatric Medicine, Department of Medicine
St Michael’s Hospital

Dan Liberman, MD, MScCH, FRCPC
Division of Geriatric Medicine, Department of Medicine
University Health Network

Thiru Yogaparan, MD, FRCP
Division of Geriatric Medicine, Department of Medicine,
Baycrest Health Sciences

Hematology

Gloria Lim, MD, MSc, FRCPC
Division of Hematology, Department of Medicine
St. Michael’s Hospital

Martina Trinkaus, MD, FRCPC
Division of Hematology, Department of Medicine
St. Michael’s Hospital

Richard Wells, MD, DPhil, FRCPC
Division of Medical Oncology and Hematology, Department of Medicine
Sunnybrook Health Sciences Centre

Infectious Diseases

Andrea K. Boggild, BSc, MSc, MD, FRCPC
Tropical Disease Unit, Toronto General Hospital
Division of Infectious Diseases, University Health Network
Department of Medicine, University of Toronto
Institute of Medical Science, University of Toronto

Paul Bunce, BSc, MA, MD, FRCPC
Division of Infectious Diseases, Department of Medicine
University Health Network

Susan M. Poutanen, MD, MPH, FRCPC
Department of Microbiology,
University Health Network & Sinai Health
Division of Infectious Diseases, Department of Medicine
University Health Network & Mount Sinai Hospital

Nephrology

Damien Noone, MB BCh BAO, MSc
Division of Paediatric Nephrology, Department of Paediatrics
The Hospital for Sick Children

Gemini Tanna, MD, FRCPC
Division of Nephrology, Department of Medicine
Sunnybrook Health Sciences Centre

Alireza Zahirieh, MD, FRCPC
Division of Nephrology
Sunnybrook Health Sciences Centre

Neurology

Lorraine Kalia, MD, PhD, FRCPC
Division of Neurology, Department of Medicine
University Health Network

Charles D. Kassardjian, MD, MSc, FRCPC
Division of Neurology, Department of Medicine
St. Michael's Hospital

Mahendra Moharir, MD, MSc, FRACP
Staff Neurologist
Division of Neurology, Department of Paediatrics
The Hospital for Sick Children

Respirology

Lee Fidler, MD, FRCPC
Division of Respirology
Sunnybrook Health Science Centre

Samir Gupta, MD, FRCPC
Division of Respirology, Department of Medicine
Unity Health Toronto

Andrew Kouri, MD, FRCPC
Division of Respirology, Department of Medicine
St. Michael’s Hospital

Christopher Li, MD, FRCPC, DABSM
Division of Respirology, Department of Medicine
St. Michael’s Hospital, Unity Health Toronto

Rheumatology

Arthur Bookman, MD, FRCPC
Division of Rheumatology, Department of Medicine
University Health Network

Shirley Lake, MD, FRCPC, MSc (QIPS)
Division of Rheumatology, Department of Medicine
Sunnybrook Health Sciences Centre

Medha L. Soowamber, MD, MSc, FRCPC
Division of Rheumatology, Department of Medicine
Mount Sinai Hospital

SURGERY

General Surgery and Thoracic Surgery

Abdollah Behzadi, MD, MBA, FRCSC, FACS
Division of Thoracic Surgery, Department of Surgery
Trillium Health Partners, University of Toronto

Laura Donahoe, MD, MSc, FRCSC
Division of Thoracic Surgery, Department of Surgery
Toronto General Hospital, University Health Network

Jesse Pasternak, MD, MPH, FRCSC
Department of General Surgery
University Health Network

Fayez Quereshy, MD, MBA, FRCSC
Department of General Surgery
University Health Network, Toronto Western Hospital

Gynaecology

Colleen McDermott, MSc, MD, FRCSC
Division of Female Pelvic Medicine & Reconstructive Surgery
Department of Obstetrics & Gynaecology
Mount Sinai Hospital

Danielle Vicus, MD, FRCSC, MSc
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology
Sunnybrook Health Sciences Centre

Fay Weisberg, MD, FRCSC
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology
University of Toronto

Neurosurgery

Sunit Das, MD, PhD
Division of Neurosurgery
St. Michael’s Hospital

Eric M. Massicotte, MD, MSc, MBA, FRCSC
Associate Professor University of Toronto
Staff Neurosurgeon, University Health Network
Director of Undergraduate Education for Neurosurgery
Medical Director, Back & Neck Program Altum Health

Obstetrics

Rohan D'Souza, MD, PhD, FRCOG, FCPS, MBBS, MSc, DNB, DGO, DFP
Department of Obstetrics and Gynecology
Mount Sinai Hospital

Richard Pittini, MD, MEd, FRCSC, FACOG
Department of Obstetrics and Gynecology, University of Toronto
Sunnybrook Health Sciences Centre

Ophthalmology

Asim Ali, MD, FRCSC
Department of Ophthalmology and Vision Sciences
The Hospital for Sick Children, University of Toronto

Wai-Ching Lam, MD, FRCSC
Department of Ophthalmology and Vision Science
University Health Network, Toronto Western Hospital

Marisa Sit, MD, FRCSC
Department of Ophthalmology and Vision Sciences
University Health Network, Toronto Western Hospital

Orthopaedics

Jeremy Hall, MD, FRCSC
Division of Orthopaedic Surgery, Department of Surgery
St. Michael’s Hospital

Paul Kuzyk, MD, MASc, FRCSC
Assistant Professor
Lower Extremity Reconstruction Surgery
Division of Orthopaedic Surgery

Sarah Ward BSc, MLA, MD, MSc
Division of Orthopaedic Surgery, Department of Surgery
St. Michael’s Hospital

Jesse Wolfstadt, MD, MSc, FRCSC
Granovsky Gluskin Division of Orthopaedic Surgery, Department of Surgery
Sinai Health System

Otolaryngology

Jonathan Irish, MD, MSc, FRCSC
Department of Otolaryngology, Head and Neck Surgery
University Health Network

Evan Propst, MD, MSc, FRCSC
Department of Otolaryngology, Head and Neck Surgery
The Hospital for Sick Children

Plastic Surgery

Siba Haykal, MD, PhD, FRCSC
Division of Plastic and Reconstructive Surgery, Department of Surgery
University Health Network

Melinda Musgrave, MD, PhD, FRCSC
Division of Plastic and Reconstructive Surgery, Department of Surgery
St. Michael’s Hospital

Urology

Sender Herschorn, BSc, MDCM, FRCSC
Division of Urology, Department of Surgery
Sunnybrook Health Sciences Centre

Yonah Krakowsky, MD, FRCSC
Division of Urology
Women’s College & Mount Sinai Hospital

Jason Lee, MD, MHPE, FRCSC
Division of Urology, Department of Surgery
University Health Network, Toronto General Hospital

Vascular Surgery

Elisa Greco, BSc, MEd, MD, RPVI, FRCSC
Vascular Surgeon, St Michael’s Hospital

George Oreopoulos, MD, MSc, FRCSC
Division of Vascular Surgery, Department of Surgery
University Health Network

 

The following external contributors revised content related to Indigenous health and history.

Erin Coates, MD
Department of Pediatrics
BC Children's Hospital

Dr. Cassandra Felske-Durksen, BSc, MD, CCFP
Indigenous Wellness Clinic, Royal Alexandra Hospital, Edmonton, Alberta
Clinical Lecturer, University of Alberta
Clinical Instructor, University of British Columbia

Tibetha Kemble (Stonechild), BMgt, MEd, PhD (Candidate)
Department of Educational Policy Studies
Faculty of Education
University of Alberta

Bob Whiteduck Crawford
Professor and Counsellor George Brown College
Member of the Snimikobi First Nation
Former Chief of the Ardoch Algonquin First Nation
President of the Board, Native Earth Performing Arts