Table Of ContentTORONTO NOTES
2020
Comprehensive medical reference and review for the
Medical Council of Canada Qualifying Exam (MCCQE) Part I and
the United States Medical Licensing Exam (USMLE) Step II
36th Edition
Editors-in-Chief:
Sara Mirali and Ayesh Seneviratne
Wherever the art of medicine is loved,
there is also a love of humanity.
– Hippocrates
Toronto Notes for Medical Students, Inc.
Toronto, Ontario, Canada
Thirty-sixth Edition
Copyright © 2020 – Toronto Notes for Medical Students, Inc.
Toronto, Ontario, Canada.
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ISBN 978-1-927363-60-7 (36th ed.)
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Cover illustration: Julia Devorak and Farah Hamade
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2 Toronto Notes 2020
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Thomas O’Brien, MD
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3 Toronto Notes 2020
Preface – From the Editors
Dear Readers,
We want to highlight the exceptional work of our
As the Editors-in-Chief of Toronto Notes 2020, we are team, composed of over 150 medical students,
proud to present this updated edition. medical illustrators, and faculty members at the
University of Toronto Faculty of Medicine. Without
Toronto Notes began humbly in 1985 from a set of the tireless effort expended by these individuals, the
student notes circulated among medical students production of Toronto Notes 2020 would not have
at the University of Toronto. Over time, Toronto been possible. In particular, we would like to highlight
Notes has grown into one of the premier study the amazing work of our executive team, all of whom
resources for generations of medical trainees. This made personal sacrifices in balancing their clinical
rich history solidified our commitment to publish a and academic duties with the responsibilities asked
comprehensive study resource for medical students of them: our production managers, Megan Drupals
engaged in clinical rotations and studying for both and Matthaeus Ware, our associate editors, Vanessa
the Canadian MCCQE Part 1 and the USMLE Step 2. Sheng, Jia Tanwani, Calvin Diep, Jagan Sivakumaran,
Danielle Jeong, and Nivethan Vela, our EBM editors,
For the past 36 years, we have remained committed Melissa Allwood, Milica Milakovic, Michael Elfassy,
to our original vision. The 2020 edition of Toronto Kimia Sheikholeslami, Khizar Karim, and Ryan Wang,
Notes contains significant improvements including: our clinical handbook editors, Priya Dhir, Helen
Genis, and Meghan Kerr, and our communication
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colour images. 2020.
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STAT notes, making it the perfect resource for all We hope that Toronto Notes 2020 enhances your
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common drugs, routes of administration, and you success in your studies and academic endeavours.
usage information.
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our newly updated Colour Atlas, our Radiology Sara Mirali, BSc (Hons), MD/PhD Candidate and
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more. Editors-in-Chief, Toronto Notes 2020
MD Program, University of Toronto
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4 Toronto Notes 2020
Acknowledgements
We would like to acknowledge the exceptional work of all previous Toronto Notes (formerly MCCQE Notes)
Editors-in-Chief and their editorial teams. The 36th edition of this text was made possible with their contributions.
2019 (35th ed.): Taraneh (Tara) Tofighi and Mark Shafarenko
2018 (34th ed.): Tina Binesh Marvasti and Sydney McQueen
2017 (33rd ed.): Jieun Kim and Ilya Mukovozov
2016 (32nd ed.): Zamir Merali and Justin D. Woodfine
2015 (31th ed.): Justin Hall and Azra Premji
2014 (30th ed.): Miliana Vojvodic and Ann Young
2013 (29th ed.): Curtis Woodford and Christopher Yao
2012 (28th ed.): Jesse M. Klostranec and David L. Kolin
2011 (27th ed.): Yingming Amy Chen and Christopher Tran
2010 (26th ed.): Simon Baxter and Gordon McSheffrey
2009 (25th ed.): Sagar Dugani and Danica Lam
2008 (24th ed.): Rebecca Colman and Ron Somogyi
2007 (23rd ed.): Marilyn Heng and Joseph Ari Greenwald
2006 (22nd ed.): Carolyn Jane Shiau and Andrew Jonathan Toren
2005 (21st ed.): Blair John Normand Leonard and Jonathan Chi-Wai Yeung
2004 (20th ed.): Andrea Molckovsky and Kashif S. Pirzada
2003 (19th ed.): Prateek Lala and Andrea Waddell
2002 (18th ed.): Neety Panu and Sunny Wong
2001 (17th ed.): Jason Yue and Gagan Ahuja
2000 (16th ed.): Marcus Law and Brian Rotenberg
1999 (15th ed.): Sofia Ahmed and Matthew Cheung
1998 (14th ed.): Marilyn Abraham and M Appleby
1997 (13th ed.): William Harris and Paul Kurdyak
1996 (12th ed.): Michael B. Chang and Laura J. Macnow
1995 (11th ed.): Ann L. Mai and Brian J. Murray
1994 (10th ed.): Kenneth Pace and Peter Ferguson
1993 (9th ed.): Joan Cheng and Russell Goldman
1992 (8th ed.): Gideon Cohen-Nehemia and Shanthi Vasudevan
All former Chief Editors from 1991 (7th ed.) to 1985 (1st ed.)
5 Toronto Notes 2020
Student Contributors
Editors-in-Chief Production Managers Clinical Handbook Website Managers/ Communications BMC Production Editors
Sara Mirali Megan Drupals Editors Atlas Editors Managers Julia Devorak
Ayesh Seneviratne Matthaeus Ware Helen Genis Sylvie Bowden Courtney Francis Farah Hamade
Priya Dhir Emily Chen Shane Natalwalla
Meghan Kerr Sandra Fiset
Amrit Sampalli
PRIMARY MEDICINE SURGERY
Associate Editors EBM Editors Associate Editors EBM Editors Associate Editors EBM Editors
Vanessa Sheng Melissa Allwood Calvin Diep Michael Elfassy Danielle Jeong Khizar Karim
Jia Tanwani Milica Milakovic Jagan Sivakumaran Kimia Sheikholeslami Nivethan Vela Ryan Wang
Chapter Editors Chapter Editors Chapter Editors
Ethical, Legal, and Family Medicine Cardiology and Infectious Diseases General Surgery and Orthopedics
Organizational Medicine Kate Dillon Cardiac Surgery Monica Shah Thoracic Surgery Akshdeep Singh Bhatia
Anna Kurdina Tiffany Got Armin Abadeh Donald Wang Kimberley Lam-Tin- Anthony Giuliano
David Wiercigroch Healey Shulman David Bobrowski Cheung Sam Keshen
Alexandra Silberberg Irakli Dzneladze Nephrology Darby Little
Anesthesia and Kimberley Lau Savar Kaul Andreea Matei Otolaryngology
Perioperative Medicine Medical Genetics Nishwa Shah Sonieya Nagarajah Amirpouyan (Pouyan)
Kosalan Akilan Sivakami Mylvaganam Endocrinology Namavarian
Nicole Falzone Ayesha Tasneem Neurology Gynecology Gianluca Sampieri
John Mikhaeil Medical Imaging Yifan Yang Megan Hird Sarah Freeman Eunice You
Mana Modares Wid Yaseen Eshita Kapoor Vanessa Rojas Luengas
Clinical Pharmacology Taryn Rohringer Cathy Meng Fei Li Ryan Ramos Plastic Surgery
Felix Chan Daniel Schlam Gastroenterology George Ho
Arman Zereshkian Arshia Javidan Respirology Neurosurgery Shawn Khan
Pediatrics Jocelyn Jia Samuel Gurupatham Connor Brenna Janakan Somasundaram
Dermatology Vinyas Harish Sechiv Jugnundan Aneesh Thakore Karanbir Brar
Josh Fletcher Alexandra Kilian Karim Mithani Urology
Khalad Maliyar Linlei Ye Geriatric Medicine Rheumatology Adam Bobrowski
Arunima Sivanand Kimberly Young Laavanya Daniel Pau Obstetrics Jethro Kwong
Dharmakulaseelan Hilary Pang Michelle Anderson Min Joon Lee
Emergency Medicine Psychiatry Fizza Manzoor Sophia Duong
Abirami Kirubarajan Maria Berseneva Hannah Tateishi Emily Li Vascular Surgery
Marissa Lu Brigida Bruno Kennedy Ayoo
Aidan McParland Daniel Kapustin Hematology Ophthalmology Brianna Barsanti-Innes
Jason Park Ronak Saluja Sze Wah Samuel Shicheng (Tony) Jin
Chan Prem Nichani
Public Health and RuiQi (Richard) Chen Daniel Sei Joon Park
Preventive Medicine Kathryn Corbett Austin Pereira
Harpreet Chahal
Ben Shachar
Vishalini Sivarajah
Copy Editors Copy Editors Copy Editors
Ethical, Legal, and Medical Genetics Cardiology and Infectious Diseases General Surgery and Orthopedics
Organizational Medicine Janis Chang Cardiac Surgery Meera Mahendiran Thoracic Surgery Anser Daud
Monisha Basu Klaudiusz Stoklosa Elliot Smith Isha Narula Emmanuel Igbokwe
Medical Imaging
Siobhan Wong Sung Hoon (Peter)
Anesthesia and Yasser Salama Nephrology Otolaryngology
Song
Perioperative Medicine Rachel Trister Endocrinology Joel George Emily DeHaas
Dong An Orly Bogler Seiwon Park Gynecology Bryan Wong
Pediatrics
Fadi Gorgi Grace Zhao Andrew Butti
Marina Atalla Neurology Plastic Surgery
Kirusanthy Kaneshwaran Xin Xu
Kristen Dietrich Gastroenterology Ortenc Hoxha Shawn Khan
Clinical Pharmacology Brian Earl Lauren Beck Valerie Kim Neurosurgery Mithila Somasundaram
Isabelle Laksono Stephanie Hosang Sara Ahmed
Geriatric Medicine Respirology Urology
Kristen Munro Hetshree Joshi
Dermatology Emily Bellicoso Erica Brant Susan Dong
Airiss Chan Psychiatry Rina Huo Obstetrics Julia Hollingsworth
Hematology
Matthew Ladda Taaha Muhammad Ye Rin (Yenah) Seo
Lauren Clarfield Rheumatology Vascular Surgery
Sheida Naderi-Azad Serena Kay Eliya Zhao
Isabella Fan Lindsay Cho Frozan Safi
Amita Mall
Emergency Medicine Vibeeshan Ophthalmology
Anuja Bhalerao Public Health and Jegatheeswaran Ruben Kalaichandran
Kiran Grant Preventive Medicine Abdul Sidiqi
Krish Bilimoria
Family Medicine
Isabelle MacLean
Casey Rosen
Jackie Tsang
BMC ILLUSTRATORS
Taeah Kim Mona Li Chloe Ng Kim Nipp Lesia Szyca Emily Taylor Rachael Whitehead Alexander Young
6 Toronto Notes 2020
Faculty Contributors, University of Toronto
All contributing professors have been appointed at the University of Toronto.
PRIMARY Joyce So, MD, PhD, FRCPC, FCCMG MEDICINE
The Fred A Litwin Family Centre in Genetic
Medicine, Department of Medicine,
Ethical, Legal, and Organizational Cardiology
Mount Sinai Hospital and
Medicine University Health Network Chi-Ming Chow, MD, CM, MSc, FRCPC
Ruby Shanker, MBBS, MHSc
Division of Cardiology, Department of
University Health Network,
Dalla Lana School of Public Health, Medical Imaging Medicine, St. Michael’s Hospital
University of Toronto
Nasir Jaffer, MD, FRCPC Paul Dorian, MD, MSc, FRCPC
Division of Abdominal Imaging, Division of Cardiology,
Anesthesia and Perioperative Medicine Department of Medical Imaging, St. Michael’s Hospital
Mount Sinai Hospital and
Ahtsham Niazi, MBBS, FCARCSI, FRCPC
University Health Network
Department of Anesthesia and Pain Anna Woo, MD CM, SM, DABIM, FRCPC
Joint Department of Medical Imaging,
Management, University Health Network University of Toronto Division of Cardiology
Department of Medicine
Jeff Wassermann, MD, FRCPC
Department of Anesthesia, John Kavanagh, MD, FRCPC University Health Network
Division of Cardiothoracic Imaging,
St. Michael’s Hospital Toronto General Hospital
Department of Medical Imaging,
Joint Department of Medical Imaging,
University of Toronto
Clinical Pharmacology Endocrinology
David Juurlink, BPhm, MD, PhD, FRCPC Julie Gilmour, MBCHB, FRCPC, MSC
Eugene Yu, MD, FRCPC
Division of Clinical Pharmacology and Department of Endocrinology,
Division of Neuroradiology,
Toxicology, Departments of Medicine and St. Michael’s Hospital
Department of Medical Imaging,
Pediatrics, Sunnybrook Health Sciences Centre
University Health Network
Karen Gomez-Hernandez, MD, MSc
Department of Endocrinology,
Dermatology Pediatrics University Health Network
David Adam, MD, FRCPC
Julie Johnstone, MD (FRCPC), MScCH Mount Sinai Hospital
Division of Dermatology, Department of
Division of Pediatric Medicine,
Medicine, St. Michael’s Hospital
Department of Pediatrics, Phillip Segal, MD, FRCPC
The Hospital for Sick Children Division of Endocrinology,
Marissa Joseph, MD, FRCPC
University Health Network
Division of Dermatology,
Laila Premji, MD, FRCPC
Department of Medicine,
Division of Paediatric Medicine,
Women’s College Hospital and
Department of Paediatrics, Gastroenterology
The Hospital for Sick Children
The Hospital for Sick Children Maria Cino, BSc(Hon), MSc, MD, FRCPC
Division of Gastroenterology,
Jensen Yeung, MD, FRCPC
Janaki Vallipuram, MD, FRCPC University Health Network,
Division of Dermatology,
Department of Pediatrics, Toronto Western Hospital
Department of Medicine,
The Hospital for Sick Children
Women’s College Hospital
Gabor Kandel, MD, FRCPC
Division of Gastroenterology,
Psychiatry Department of Medicine,
Emergency Medicine
Benoit Mulsant, MD, MS, FRCPC St. Michael’s Hospital
Mark Freedman, MD, FRCPC
Department of Psychiatry,
Department of Emergency Medicine,
Centre for Addiction and Mental Health Piero Tartaro, MD, MSc, FRCPC
Sunnybrook Health Sciences Centre
Division of Gastroenterology,
Dr. Mary Preisman, MD, FRCPC Department of Medicine,
Fernando Teixeira, MD, FRCPC
Department of Psychiatry, Sunnybrook Health Sciences Centre
Department of Emergency Medicine,
Mount Sinai Hospital
St. Michael’s Hospital
Dr. Amit Rotem, MD Geriatric Medicine
Family Medicine Department of Psychiatry, Vicky Chau, MD, MScCH, FRCPC
Ruby Alvi, MD, CCFP, MHSc Centre for Addiction and Mental Health Division of Geriatric Medicine,
Department of Family and Community Department of Medicine,
Medicine, University of Toronto Dr. Ilana Heather Shawn, MD, FRCPC University Health Network
Department of Psychiatry,
Azadeh (Azi) Moaveni, MD, CCFP St. Michael’s Hospital Karen D’Silva, MD, MS, FRCPC
Department of Family and Community Division of Geriatrics,
Medicine, University Health Network, St Michael’s Hospital
Public Health and Preventive Medicine
Toronto Western Hospital
Barry Pakes, BSc, MD, MPH, CCFP, DTMH, Dan Liberman, MD, MScCH, FRCPC
Dr. Sherylan Young, MD, CCFP, FCFP FRCPC, PhD Division of Geriatric Medicine,
Department of Family and Community Dalla Lana School of Public Health, Department of Medicine,
Medicine, Sunnybrook Health Sciences Centre University of Toronto University Health Network
Nav Persaud, MD, MSc, BA, BSc
Medical Genetics Department of Family and Community Hematology
Hanna Faghfoury, MDCM, FRCPC, FCCMG Medicine, St. Michael’s Hospital Gloria Lim, MD, MSc, FRCPC
The Fred A Litwin Family Centre in Genetic Department of Family and Community Division of Hematology,
Medicine, Department of Medicine, Medicine, University of Toronto Department of Medicine,
Mount Sinai Hospital and St. Michael’s Hospital
University Health Network
7 Toronto Notes 2020
Faculty Contributors, University of Toronto
Martina Trinkaus, MD, FRCPC SURGERY Joshua Teichman, MD, FRCSC
Division of Hematology, Department of Ophthalmology,
Department of Medicine, Trillium Health Partners
General Surgery and Thoracic Surgery
St. Michael’s Hospital
Abdollah Behzadi, MD, MBA, FRCSC, FACS
Richard Wells, MD, D.Phil, FRCPC Department of General Surgery, Orthopedics
Trillium Health Partners
Division of Medical Oncology and Jeremy Hall, MD, FRCSC
Hematology, Department of Medicine, Dvision of Orthopedic Surgery,
Sunnybrook Health Sciences Centre Michael Ko, MD, PhD, FRCSC Department of Surgery,
Department of General Surgery, St. Michael’s Hospital
St Joseph’s Health Care
Herb von Schroeder, MD, MSc, FRCSC
Infectious Diseases
Jesse Pasternak, MD, MPH, FRCSC Divisions of Orthopedic Surgery and
Ari Bitnun, MD, MSc, FRCPC Department of General Surgery, Plastic Surgery, Department of Surgery,
Division of Infectious Diseases, University Health Network University Health Network
Department of Medicine,
The Hospital for Sick Children Fayez Quereshy, MD, MBA, FRCSC Sarah Ward, MD, MLA, MSc , FRCSC
Department of General Surgery, Divisions of Orthopedic Surgery,
Paul Bunce, BSc, MA, MD, FRCPC University Health Network, Department of Surgery,
Division of Infectious Diseases, Toronto Western Hospital St. Michael’s Hospital
Department of Medicine,
University Health Network Dr. David Wasserstein, MD, FRCSC, MSc,
Gynecology
MPH(c)
Susan M. Poutanen, MD, MPH, FRCPC Sari Kives, MD, FRCSC Division of Orthopaedic Surgery,
Department of Microbiology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre
University Health Network St. Michael’s Hospital and
Mount Sinai Hospital The Hospital for Sick Children
Otolaryngology
Danielle Vicus, MD, FRCSC, MSc
Jonathan Irish, MD, MSc, FRCSC
Department of Obstetrics and Gynecology,
Nephrology Department of Otolaryngology -
Sunnybrook Health Sciences Centre
Zahirieh Alireza, MD, FRCPC Head and Neck Surgery,
Division of Nephrology, Fay Weisberg, MD, FRCSC University Health Network
Sunnybrook Health Sciences Centre Division of Reproductive Endocrinology
Evan Propst, MD, MSc, FRCSC
and Infertility, Department of Obstetrics and
Department of Otolaryngology -
Istvan Mucsi, MD, PhD, FRCPC Gynecology, University of Toronto
Head and Neck Surgery,
Multi-Organ Transplant Program and
The Hospital for Sick Children
Division of Nephrology,
University Health Network Neurosurgery
Todd Mainprize, MD, FRCSC Plastic Surgery
Gemini Tanna, MD, FRCPC Department of Neurosurgery, Siba Haykal, MD, PhD, FRCSC
Division of Nephrology, Sunnybrook Health Sciences Centre Division of Plastic and Reconstructive Surgery,
Department of Medicine, Department of Surgery,
Sunnybrook Health Sciences Centre Eric Massicotte, MD, MSc, FRCSC University Health Network
Department of Neurosurgery,
University Health Network,
Melinda Musgrave, MD, PhD, FRCSC
Neurology Toronto Western Hospital Division of Plastic and Reconstructive Surgery,
Esther Bui, MD, FRCPC Department of Surgery, St. Michael’s Hospital
Division of Neurology,
Obstetrics
Department of Medicine,
University Health Network Rohan D’Souza, MD, MSc, FRCOG, PhD (C) Urology
Department of Obstetrics and Gynecology,
Sender Herschorn, MDCM, FRCSC
Mount Sinai Hospital
Xavier Montalban, MD, PhD Division of Urology, Department of Surgery,
Division of Neurology, Sunnybrook Health Sciences Centre and
Richard Pittini, MD, MEd, FRCSC, FACOG
Department of Medicine, Women’s College Hospital
Department of Obstetrics and Gynecology,
St. Michael’s Hospital
University of Toronto, Sunnybrook Health
Jason Lee, MD, MHPE, FRCSC
Sciences Centre
Division of Urology, Department of Surgery,
University Health Network,
Respirology Amanda Selk, MD, FRCSC
Toronto General Hospital
Anju Anand, MD, FRCPC Department of Obstetrics and Gynecology,
Divison of Respirology, Mount Sinai Hospital
Department of Medicine,
Vascular Surgery
St. Michael’s Hospital
Elisa Greco, BSc, MBChB, MD, FRCS
Ophthalmology
Division of Vascular Surgery,
Meyer Balter, MD, FRCPC, FACP, FCCP Asim Ali, MD, FRCSC
Department of Surgery,
Division of Respiratory Medicine, Department of Opthalmology and
St. Michael’s Hospital
Mount Sinai Hospital Vision Sciences, The Hospital for Sick
Children, University of Toronto
George Oreopoulos, MD, MSc, FRCSC
Division of Vascular Surgery,
Rheumatology Wai-Ching Lam, MD, FRCSC Department of Surgery,
Simon Carette, MD, FRCPC Department of Ophthalmology and University Health Network
Division of Rheumatology, Vision Science, University Health Network,
Department of Medicine, Toronto Western Hospital
Mount Sinai Hospital
Marisa Sit, MD, FRCSC
Arthur Bookman, MD, FRCPC Department of Opthalmology and
Division of Rheumatology, Vision Sciences, University Health Network,
University Health Network Toronto Western Hospital
8 Toronto Notes 2020
Table of Contents
Index Abbreviations
Common Unit Conversions
Commonly Measured Laboratory Values
Ethical, Legal, and Organizational Medicine ................................................. ELOM
Anesthesia and Perioperative Medicine..................................................... A
Cardiology and Cardiac Surgery........................................................... C
Clinical Pharmacology ................................................................... CP
Dermatology........................................................................... D
Emergency Medicine .................................................................... ER
Endocrinology.......................................................................... E
Family Medicine ........................................................................ FM
Gastroenterology ....................................................................... G
General Surgery and Thoracic Surgery...................................................... GS
Geriatric Medicine ...................................................................... GM
Gynecology............................................................................ GY
Hematology............................................................................ H
Infectious Diseases...................................................................... ID
Medical Genetics .......................................................................MG
Medical Imaging........................................................................ MI
Nephrology............................................................................ NP
Neurology ............................................................................. N
Neurosurgery .......................................................................... NS
Obstetrics ............................................................................. OB
Ophthalmology......................................................................... OP
Orthopedic Surgery ..................................................................... OR
Otolaryngology......................................................................... OT
Pediatrics.............................................................................. P
Plastic Surgery ......................................................................... PL
Psychiatry ............................................................................. PS
Public Health and Preventive Medicine ..................................................... PH
Respirology............................................................................ R
Rheumatology.......................................................................... RH
Urology ............................................................................... U
Vascular Surgery........................................................................ VS
Index
9 Toronto Notes 2020
