TORONTO NOTES

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COMPREHENSIVE MEDICAL REFERENCE

AND A REVIEW FOR MCCQE +

Editors-in-Chief •Anders Erickson & Jennifer Parker

Associate Editors, Primary •Dorrin Zarrin Khat & Ming Li

Associate Editors, Medicine •Karolina Gaebe & Alyssa Li

Associate Editors, Surgery •Vrati Mehra & Chunyi Christie Tan

TORONTO NOTES

2023

Comprehensive Medical Reference

and a Review for the Medical Council of Canada Qualifying Exam

(MCCQE)

39th Edition

Editors-in-Chief:

Anders W. Erickson & Jennifer Parker

Toronto Notes for Medical Students, Inc.

Toronto, Ontario, Canada +

AL GRAWANY

2 Editorial Toronto Xotcs 2023

Thirty-ninth Edition

Copyright © 2023 - Toronto Notes for Medical Students,Inc. Toronto, Ontario, Canada

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ISBN 978-1-998874-01-9 (39th ed.)

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It is made available on the condition that the information contained herein will not be sold or photocopied. No part of this

publication may be used or reproduced in any form or by any means without prior written permission from the publisher.

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effort has been made to obtain permission for all copyrighted material contained herein. Previous editions copyright

© 1985 to 2023.

Cover illustration:Jennifer Xin Ran Shao and Aimy Meng Yu Wang

Illustrations:Biomedical Communications, University of Toronto

Notice:

THIS PUBLICATION HAS NOT BEEN AUTHORED, REVIEWED, OR OTHERWISE SUPPORTED BY THE

MEDICAL COUNCIL OF CANADA NOR DOES IT RECEIVE ENDORSEMENT BY THE MEDICAL COUNCIL AS

REVIEW MATERIALFORTHEMCCQEPARTI.THISPUBLICATIONHAS NOTBEEN AUTHORED,REVIEWED,

OR OTHERWISE SUPPORTED BY THE NATIONAL BOARD OF MEDICAL EXAMINERS U.S.A. NOR DOES IT

RECEIVE ENDORSEMENT BY THE NATIONAL BOARD AS REVIEW MATERIAL FOR THE USMLE.

The editors of this edition have taken every effort to ensure that the information contained herein is accurate and conforms

to the standards accepted at the time of publication. However, due to the constantly changing nature of the medical

sciences and the possibility of human error, the reader is encouraged to exercise individual clinical judgement and consult

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Library of Congress Cataloging-in-Publication Data is available upon request

3Editorial Toronto Notes 2023

Dedicated to all the many contributors and supporters of Toronto Notes,

both past and present,

who have shaped the 2023 edition!

The Toronto Notes for Medical Students is dedicated to helping fund many charitable endeavours and medical student

initiatives at the University of Toronto’s Faculty of Medicine and beyond. Programs that have received Toronto Notes for

Medical Students funding include:

Community Affairs Programs

Adventuresin Science (.VIS)

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Growing Up Healthy

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Other Sponsorships

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Classformats and graduations

NOTE:

Many of you have wondered about the Toronto Notes logo,which is based on the rod of Asclepius, the Greek god of

medicine. The rod of Asclepius consists of a single serpent entwined around a staff.This icon symbolizesboth rebirth, by

way of a snake shedding itsskin,and also authority, by way of the staff.

In ancient Greek mythology, Asclepius was the son of Apollo and a skilled practitioner of medicine who learned

the medical arts from the centaur Chiron. Asclepius’ healing abilities were so great that he was said to be able to bring

back people from the dead.These powers displeased the gods, who punished Asclepius by placing him in the sky as the

constellation Orphiudius.

The rod of Asclepius is at times confused with the caduceus,or wand, of Hermes, a staff entwined with two serpents

and often depicted with wings.The caduceus is often used as a symbol of medicine or medical professionals, but there is

little historical basis for thissymbolism.

As you may have guessed,our logo uses the rod of Asclepius that is modified to also resemble theCN Tower - our way

of recognizing the university and community in which we have been privileged to learn the art and science of medicine.

Thomas O’Brien, MD +

Class of 2009, M.D. Program, University of Toronto

AL GRAWANY

4 Editorial Toronto Notes 2023

Preface - From the Editors

and the Climate Crisis are also fully addressed. In addition to

content updates, theToronto Notes 2023Clinical Handbook has

been restructured to prioritize high-yield content to guide your

learning during clerkship rotations. Toronto Notes prioritizes

cultural sensitivity, health equity, and strives for accurate

representation of our vibrant and diverse communities. To

enhance our team’s editorial lens on these concepts while editing

the chapters, training was provided by the Anti-Racism and

Cultural Diversity Office and Office of Inclusion & Diversity at

the University of Toronto.

Dear reader.

We are grateful to present Toronto Notes 2023 to you. This

edition is the product of an exceptional effort from the

hundreds of editors and contributors who worked tirelessly with

us as we navigated through the year.Together, we have created

the thirty-ninth edition of Toronto Notes, thus continuing

our organization'

s rich tradition of providing an up-to-date,

comprehensive, and concisely written medical resource to our

readers.

We sincerely thank each of our 170 student editors and

103 faculty editors, whose meticulous revisions and shared

dedication to the bettering of this text has helped make Toronto

Notes 2023 possible.We have learned so much from leading this

team, and are especially grateful to everyone for contributions

to Toronto Notes with challenging time commitments and

demands. We thank our incredible Associate Editors - Ming

Li, Dorrin Zarrin Khat, Christie Ian, Yrati Mehra, Alyssa Li,

and Karolina Gaebe - for their tireless leadership, exceptional

organization, and wonderful teamwork. We, and the success of

this edition, lean on their shoulders.We also thank our Clinical

Handbook Editors - Justin Lu,

lanice Chan, and Rayoun

Ramendra - for their exceptional editorial leadership and

spearheading the work on this resource. We owe a great deal

of gratitude to the Editors-in-Chief of the 2022 edition - Yuliya

Lytvyn and Maleeha Qazi - for their continued guidance over

the past two years. We would also like to thank the wonderful

BMC illustration team for their work and especially the cover

designs, with inspiration from the medical illustrations of

Barry T.O'Neil. Lastly, we thank our longtime partners at Type

& Graphics Inc - especially our backbone, Enrica Aguilera

and Maria Garcia — for their years of support and excellent

work producing Toronto Notes 2023. Finally, we thank you

for supporting our initiative by purchasing and reading our

product We hope that you will find Toronto Notes 2023 to be a

useful companion on your medical journey, both now and for

years to come.

Thirty-nine years ago, Toronto Notes began as a humble

initiative,with medical students from the University of Toronto

collecting and circulating their notes. Nearly four decades later

- with annual editions and an ever-expanding vision -Toronto

Notes has become one of the most trusted medical review texts;

it is a resource that is cherished by trainees and physicians

throughout Canada and around the world.

The Toronto Notes for Medical Students Inc. is a nonprofit

corporation whose mission is to proride a trusted medical

resource in order to give back to our community. Keeping in

line with our values and community needs, all proceeds from

Toronto Notes sales are directly donated to support both

global and local initiatives. Among other initiatives, we have

supported U ofT Medicine class activities,studentscholarships

and bursaries (such as the Mohammad and Zevnab Asadi-Lari

award), our Daffy annual musical fundraiser for the Canadian

Cancer Society, and the entirety of our (over twenty-five)

student-led outreach programs that seek to enrich lives in the

community.