Ebook Toronto notes 2018 (34/E): Part 2

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Part 2 book “Toronto notes 2018” has contents: Medical genetics, medical imaging, population health and epidemiology, plastic surgery, vascular surgery, rheumatology, respirology, psychiatry, otolaryngology, orthopedics, ophthalmology, neurosurgery, neurology,… and other contents. Medical Genetics c MG bo ok Spencer van Mil, chapter editor Sheliza Halani and Taraneh Tofighi, associate editors Arnav Agarwal and Sukhmani Sodhi, EBM editors Dr Hanna Faghfoury and Dr Joyce So, staff editors Acronyms co m Introduction to Genetics Background Pedigrees Genetic Testing and Counselling ee Dysmorphisms Congenital Anomalies Approach to the Dysmorphic Child Syndromes and Diseases Large Genomic Changes Single Gene Disorders Metabolic Diseases References Medical Genetics MG1 Toronto Notes 2018 MG2 Medical Genetics Toronto Notes 2018 c Acronyms fr Acronyms ONTD open neural tube defect PKUphenylketonuria SCID severe combined immunodeficiency USultrasound ok k cystic fibrosis copy number variation fluorescence in situ hybridization first trimester screening integrated prenatal screening b CF CNV FISH FTS IPS Introduction to Genetics o Background eb eb bo oo sf re ok sf re e e Terms • Penetrance: extent that a gene is observably expressed in an individual that carries it • Expressivity: extent of gene expression • Genetic heterogeneity: genetic disorder can arise from different allele/locus mutations • Phenotypic heterogeneity: mutations in the same gene resulting in multiple diverse clinical manifestations and degree of severity • Imprinting: epigenetic process that involves methylation or acetylation of DNA, affecting gene expression • Uniparental disomy: two full or partial copies of a chromosome from one parent and no chromosome from the other parent m m Mendelian Inheritance • disorders caused by mutation of one or both copies (alleles) of a gene, inherited in one of two patterns ■■ autosomal: when disorder is caused by genes on one of 22 pairs of autosomes (chromosomes 1-22) ■■ X-linked: when disease is caused by a gene on the X chromosome ee ee Triplet Repeat Expansions • disorder in which trinucleotide repeats in certain genes exceed the normal number and result in altered gene expression or production of an abnormal protein (e.g Fragile X syndrome, Huntington's disease) bo k bo bo ok sf Imprinting Disorders • imprinted genes are expressed entirely from either the maternal or paternal allele, depending on the gene (parent-of-origin gene expression) • occur when a mutation disrupts the normally expressed allele of imprinted gene (e.g Prader-Willi syndrome, Angelman syndrome, Beckwith-Wiedemann syndrome) or through uniparental disomy of the normally silenced allele om co m Mitochondrial Disorders • disorders caused by mutations of the DNA present in mitochondria or nuclear genes whose protein products are important for mitochondrial function • inheritance pattern of mitochondrial DNA mutations: mother passes on the defect to all her children; father cannot pass on defect since embryo only receives mitochondria from the mother (in the egg) fre ks oo oo ks fe e Copy Number Variation • difference in the amount of genetic material ■■ decrease: deletion of a chromosomal region, leaving only one copy of the genetic material in that region (e g 22q11.2 deletion syndrome due to deletion on chromosome 22) ■■ increase duplication of a chromosomal region, resulting in more than two copies of the genetic material in that region (e.g Potocki-Lupski syndrome due to duplication of chromosome 17p11.2) • CNVs can be part of normal range of genetic variation MG3 Medical Genetics Toronto Notes 2018 c Introduction to Genetics fre Pedigrees Married/Partners Female, unaffected Divorced/Separated Spontaneous Abortion e Male, unafffected m ok k • diagrams that show the pattern/distribution of phenotypes for a genetic disorder within a family, often across multiple generations Termination of Pregnancy Consanguinity Deceased Infertility re Affected Individual s Carrier unaffected at this time but could manifest disease later Adopted Sibling Siblings (listed from left to right (oldest to youngest) No Offspring by choice Affected Individual ≥2 conditions P Dizygous Twins (fraternal) Pregnancy o P bo Carrier not likely to manifest disease Ectopic Pregnancy ECT Gender Unknown, unaffected SB Monozyous Twins (identical) Stillbirth (write SB and gestational age if known) SB Figure Common pedigree symbols co Genetic Testing and Counselling re e c om Whole-Genome Sequencing Expands Diagnostic Utility and Improves Clinical Management in Paediatric Medicine Genomic Med 2016;1:15012 While the standard of care for neurodevelopmental and congenital malformations is chromosome microarray analysis for copy number variations, whole exome sequencing a lows the identification of sequence-level mutations across all known coding genes Whole genome sequencing has been previo sly associated with a diagnostic yield of ~25% for neurological disorders or congenital anomalies A recent study published in Genomic Medicine has demonstrated that whole genome sequencing exceeds other technologies in detecting genetic variants with a 34% diagnostic yield, a four-fold increase in molecular diagnosis relative to chromosome microarray analysis and a two-fold increase relative to all genetic testing protocols These results suggest that whole genome sequencing may be used as a first-tier molecular test in individuals with development delays and congenital abnormalities, with a higher diagnostic yield than conventional genetic testing and decreased time to genetic diagnosis m sf m ee fre e c o o m e e o oo s ks fre e om om m b bo bo ok ks sf fr re • microarray analysis ■■ array comparative genomic hybridization (CGH): a collection of DNA probes attached to a solid surface to which test DNA hybridizes in order to determine copy number of DNA regions ■■ microarray analysis can identify small deletions or duplications of genetic material anywhere in the genome ■■ commonly indicated when there is developmental delay OR two or more congenital anomalies • FISH (fluorescence in situ hybridization): a DNA probe used to identify a gain or loss of chromosomal material • karyotype: microscopic analysis of chromosomes with a special stain that shows large changes in the number or structure of chromosomes; can detect large CNVs • Sanger sequencing: the ‘gold-standard’ method for identification of single nucletotide variants in short DNA sequences (e.g the exons of the gene(s) known to cause suspected syndrome) • next-generation sequencing: high throughput method to sequence exomes or whole-genomes; useful when genetic syndrome is suspected, but diagnosis is unclear: increasingly used for multi-gene test panels • prenatal screening ■■ offer optional prenatal screening before diagnostic testing ■■ first trimester screening (FTS) ◆◆ biochemistry (b-hCG, PAPP-A) ◆◆ US est mate of gestational age and measurement of nuchal translucency ◆◆ screen for trisomy 21 and 18 ◆◆ done between 11 and 14 wk, sensitivity=80-85% ■■ integrated prenatal screening (IPS) ◆◆ ONTD, trisomy 21 and 18 ◆◆ use results from FTS and combine with additional biomarkers completed between 15-21 weeks (inhibin A, unconjugated estradiol, AFP, 2nd trimester b-hCG) ◆◆ improved sensitivity, reduced false positive rate compared to FTS ■■ fetal anatomy scan ◆◆ US at 18-20 wk • newborn screening ■■ detect potentially fatal, treatable disorders before symptoms begin to allow for early therapy ■■ performed on all newborns in Canada ■■ heel puncture to collect blood ■■ screens for CF, congenital hypothyroidism, congenital adrenal hyperplasia, SCID, hemoglobinopathies, metabolic diseases, etc MG4 Medical Genetics Toronto Notes 2018 c Dysmorphisms fr Dysmorphisms o Congenital Anomalies m e e b Minor and Major Anomalies minor anomaly: an unusual anatomic feature that is of no serious medical or cosmetic consequence to the patient • major anomaly: anomaly that creates significant medical, surgical, or cosmetic problems for the patient fre fre e e m co m Mechanism for Anomalies • malformation: results from an intrinsically abnormal developmental process (e.g polydactyly) • disruption: results from the extrinsic breakdown of, or interference with, an originally normal developmental process (e g amniotic band disruption sequence) • deformation: alteration of the final form of a structure by mechanical forces (e.g Potter deformation sequence) • dysplasia: abnormal development that results in abnormal organization of cells into tissues (e.g bone dysplasia) eb m om m eb o bo o Multiple Anomalies • association: non-random occurrence of multiple independent anomalies that appear together more than would be predicted by chance but are not known to have a single etiology (e.g VACTERL) • sequence: related anomalies that come from a single initial major anomaly or precipitating factor that changes the development of other surrounding or related tissues or structures (e.g Potter sequence or Pierre-Robin sequence) • syndrome: a pattern of anomalies that occur together and are known or thought to have a single cause (e.g Down syndrome) o Approach to the Dysmorphic Child e e • congenital abnormalities are the most common cause of infant death in developed countries o ok sf r General Approach to the Dysmorphic Child • Are the anomalies major or minor? • What is the mechanism underlying the anomaly? • Do the anomalies fit as part of an association, sequence, or syndrome? e m m e b History • prenatal/obstetrical history (see Obstetrics, OB4) with particular attention to potential teratogenic exposures, developmental history (see Pediatrics, P22), and past medical history • complete generation family pedigree: health history, consanguinity, stillbirths, neonatal deaths, specific illnesses, intellectual disability, multiple miscarriages, ethnicity Physical Exam re Ears: structure, size, placement, rotation Skull: contour and symmetry Hair: texture, pattern Eyes: distance apart, brows, lashes, folds, creases, coloboma, fundus o Nose: nasal bridge, nostrils Philtrum: length, shape Mouth: lips, palate, tongue, teeth fre Face: gestalt Spine: scoliosis, kyphosis Chin: size, position e Skin: hair tufts, sacral dimples, sinus m Neck: webbed, redundant nuchal skin Thorax: shape, size, nipple spacing Limbs: proportions, amputations Genitalia: ambiguous ee co Hands and Feet: creases, structure, nails Growth parameters (head circumference, height, weight) fr Figure Physical exam of the dysmorphic child VACTERL Association VVertebral dysgenesis AAnal atresia (imperforate anus) ± fistula CCardiac anomalies T-ETracheoEsophageal fistula ± esophageal atresia RRenal anomalies LLimb anomalies MG5 Medical Genetics Toronto Notes 2018 Syndromes and Diseases oo ks fr Investigations • screening for TORCH infections • serial photographs if child is older • x-rays for bony abnormalities • cytogenetic studies ■■ karyotype if recognized aneuploidy syndrome ■■ chromosomal microarray analysis (array comparative genomic hybridization) if developmental delay OR two or more congenital anomalies ■■ FISH if aneuploidy syndrome (e.g trisomy 13, 18 or 21) suspected • biochemistry: various biochemical profiles, specific enzyme assays • single gene testing, multi-gene panel testing m eb b Check the umbilical cord for arteries and vein The presence of a single umbilical artery may be associated with other congenital anomalies fe sf re e e c co Management • prenatal counselling and assessing risk of recurrence • referral for specialized pediatric or genetic care for symptomatic management • specific treatments are available for certain metabolic disorders and genetic syndromes ■■ metabolic disorders: enzyme replacement therapy, substrate reduction therapy, etc (e.g low-protein diet in PKU patients) ■■ genetic syndromes: e.g mTOR inhibitors in tuberous sclerosis oo oo Syndromes and Diseases m e Large Genomic Changes Table Trisomy Chromosomal Syndromes Trisomy 13 Disease Patau syndrome Incidence 1:600-800 births Most common abnormality of autosomal chromosomes Rises with advanced maternal age from 1:1,500 at age 20 to 1:20 by age 45 co Trisomy 18 Edwards’ syndrome 1:10,000 live births c 1:6,000 live births F:M = 3:1 r Microcephaly, prominent occiput Microcephaly, sloping forehead, occipital scalp defect, holoprosencephaly s Mild microcephaly, flat occiput, 3rd fontanelle, brachycephaly Microphthalmia, corneal abnormalities Ears Low-set, small, overfolded upper helix frequent AOM, hearing loss Low-set, malformed Low-set, malformed Facial Features Protruding tongue, large cheeks, low flat nasal bridge, small nose Cleft lip/palate Small mouth, micrognathia 60-80% cleft lip and palate Skeletal/MSK Short stature Excess nuchal skin Joint hyperflexibility (80%) including dysplastic hips, vertebral anomalies, atlantoaxial instability Short stature Clenched fist with overlapping digits, hypoplastic nails, clinodactyly, polydactyly Severe growth retardation Polydactyly, clenched hand Cardiac Defect 50%, pa ticularly atrioventricular septal defect 60% (VSD, PDA, ASD) 80% (VSD PDA, ASD) GI Duodenal/esophageal/anal atresia, TEF, Hirschsprung’s disease, chronic constipation Hernia, TEF GU Cryptorchidism, rarely fertile Polycystic kidneys, cryptorchidism CNS Hypotonia at birth Low IQ, developmental delay, hearing problems Onset of Alzheimer’s disease in 40s Hypertonia Hypo- or hypertonia Seizures, deafness Severe developmental delay Other Features Transverse palmar crease, clinodactyly, and absent middle phalanx of the 5th finger 1% lifetime risk of leukemia Polycythemia Hypothyroidism SGA Rocker-bottom feet Single umbilical artery Midline anomalies: scalp, pituitary, palate, heart, umbilicus, anus Rocker-bottom feet Prognosis/ Management Prognosis: long term management per AAP Guidelines (Health Supervision of Children with Down syndrome), recommend chromosomal analysis, CBC, Echo, yearly thyroid test, atlanto-occipital x-ray at yr, sleep study, hearing test, and ophthalmology assessment 13% 1-year survival, 10% ten-year survival Profound intellectual disability in survivors 20% 1-year survival, 13% ten-year survival Profound intellectual disability in survivors e k Polycystic kidneys co co m b e eb m m co co ee om Microphthalmia, hypotelorism, iris coloboma, retinal anomalies om Upslanting palpebral fissures, inner epicanthal folds, speckled iris (Brushfield spots), refractive errors (myopia), acquired cataracts, nystagmus, strabismus oo Eyes e Cranium/Brain re e co Trisomy 21 Down syndrome MG6 Medical Genetics Toronto Notes 2018 c Syndromes and Diseases fr e Table Common Genetic Disorders Involving the Sex Chromosomes Klinefelter Syndrome Turner Syndrome 45,X (most common) f Fragile X Syndrome 47,XXY (most common) 48,XXXY, 49,XXXXY Incidence 1:3,600 males, 1:6,000 females Most common heritable cause of intellectual disability in boys 1:1,000 live male births Increased risk with advanced maternal age 1:4,000 live female births Risk not increased with advanced maternal age Phenotype Overgrowth: prominent jaw, forehead, and nasal bridge with long and thin face, large protuberant ears, macroorchidism, hyperextensibility, and high arched palate Complications: seizures, scoliosis, mitral valve prolapse Tall, slim, underweight No features prepuberty Postpuberty: male may suffer from developmental delay, long limbs, gynecomastia, lack of facial hair Short stature, short webbed neck, low posterior hair line, wide carrying angle Broad chest, widely spaced nipples Lymphedema of hands and/or feet, cystic hygroma in newborn with polyhydramnios, lung hypoplasia Coarctation of aorta, bicuspid aortic valve Renal and cardiovascular abnormalities, increased risk of HTN Less severe spectrum with mosaic IQ and Behaviour Mild to moderate intellectual disability, 20% of affected males have normal IQ ADHD and/or autism Female carriers may show intellectual impairment Male carriers may demonstrate tremor/ataxia syndrome in later life Mild intellectual disability Behavioural or psychiatric disorders – anxiety, shyness, aggressive behaviour, antisocial acts Mild intellectual disability to normal intelligence Gonad and Reproductive Function Premutation carrier females at risk of developing premature ovarian failure Infertility due to hypogonadism/hypospermia Streak ovaries with deficient follicles, infertility, primary amenorrhea, impaired development of secondary sexual characteristics Diagnosis/ Prognosis/ Management Molecular testing of FMR1 gene: overamplification of the trinucleotide repeat, length of segment is proportional to severity of clinical phenotype (genetic anticipation) Increased risk of germ cell tumours and breast cancer Management: testosterone in adolescence Normal life expectancy if no complications Increased risk of X-linked diseases Management: Echo, ECG to screen for cardiac malformation GH therapy for short stature Estrogen replacement at time of puberty for development of secondary sexual characteristics m co m sf r s m fre e om m om co m m bo ks e om co m m k X-linked Genetic anticipation CGG trinucleotide repeat on X chromosome measurable by molecular analysis m Genotype Noonan Syndrome CHARGE Syndrome Lack of expression of genes on paternal chromosome 15q11-13 due to deletion, maternal uniparental disomy of chromosome 15, or imprinting defect Lack of expression of genes on maternal chromosome 15q11-13 due to deletion or inactivation or paternal uniparental disomy Autosomal dominant with variable expression PTPN11 mutation most common cause but multiple genes known 2/3 of children with CHARGE have been found to have a CHD7 mutation on chromosome 10,000 e Incidence 1:4000; Second most common genetic diagnosis (next to Down syndrome) 1:15,000 1:10,000 1:2,000 male and female live births “CATCH 22” Cyanotic CHD Anomalies: craniofacial anomalies, micrognathia and low set ears Thymic hypoplasia: immunodeficiency Cognitive impairment Hypoparathyroidism, hypocalcemia 22q11 microdeletions High risk for schizophrenia and other psych disorders “H3O”: Hypotonia and weakness, Hypogonadism, obsessive Hyperphagia, Obesity Short stature, almond-shaped eyes, small hands and feet with tapering of fingers Developmental delay (variable) Hypopigmentation, type DM Ataxia with severe intellectual disability, seizures, tremulousness, hypotonia Midface hypoplasia, fair hair, uncontrollable laughter Short stature, webbed neck, triangular facies hypertelorism, low set ears, epicanthal fo ds, ptosis, pectus excavatum Right sided CHD, pulmonary stenosis Increased risk of hematological cancers, moderate intellectual disability, delayed puberty oo ks eb sf oo eb m co ee Clinical Features fr Microdeletions of chromosome region 22q11.2 m Genotype m Angelman Syndrome o Prader-Willi Syndrome o 22q11.2 Deletion Syndrome o ok Table Other Genetic Syndromes “CHARGE” CColoboma Hcongenital Heart disease Achoanal Atresia Rmental Retardation G GU anomalies EEar anomalies MG7 Medical Genetics Toronto Notes 2018 Syndromes and Diseases Gene Associated Cancers TP53 k Li-Fraumeni Syndrome ok sf Syndrome re Table Familial Cancer Syndromes Breast, osteosarcoma, leukemia, soft tissue carcinoma, and numerous other cancers FAP APC Colorectal, small intestine/stomach tumours Hereditary Breast and Ovarian Cancer Syndrome BRCA1, BRCA2 Female: breast, ovarian, pancreatic Male: prostate, breast, pancreatic Von Hippel-Lindau Syndrome VHL Kidney + tumours (e.g pheochromocytoma) PTEN Breast, thyroid, endometrial m m Cowden Syndrome Colorectal, endometrial, ovarian, renal, pancreatic, liver/biliary duct, stomach, brain, breast bo MSH2, MLH1, MSH6, PMS2, EPCAM bo Lynch Syndrome (HNPCC) NF Astrocytoma, optic glioma, neurofibroma, leukemia Vestibular schwannoma, meningioma, ependymoma, astrocytoma e NF1 NF2 sf re Type Type o Single Gene Disorders e CYSTIC FIBROSIS • see Respirology, R12 and Pediatrics, P82 SICKLE CELL DISEASE • see Hematology, H20 o DUCHENNE MUSCULAR DYSTROPHY Epidemiology • 1:4,000 males oo oo k ks Etiology • one type of muscular dystrophy characterized by progressive skeletal and cardiac muscle degeneration • X-linked recessive: 1/3 spontaneous mutations, 2/3 inherited mutations • missing structural protein (dystrophin) → muscle fibre fragility → fibre breakdown → necrosis and regeneration m Clinical Presentation • proximal muscle weakness by age 3, positive Gower’s sign, waddling gait, toe walking • pseudohypertrophy of calf muscles (muscle replaced by fat) and wasting of thigh muscles • decreased reflexes • non-progressive delayed motor and cognitive development (dysfunctional dystrophin in brain) •cardiomyopathy ks fre e Diagnosis • molecular genetic studies of dystrophin gene (DMD) (first line) • family history (pedigree analysis) • increased CK (50-100x normal) and lactate dehydrogenase • elevated transaminases • muscle biopsy, EMG m eb bo Management • supportive (e.g physiotherapy, wheelchairs, braces , prevent obesity • cardiac health monitoring and early intervention • bone health monitoring and intervention (vitamin D, bisphosphonates) • steroids (e.g prednisone or deflazacort) • surgical (for scoliosis) • gene therapy trials underway ee ee c Complications • patient usually wheelchair-bound by 12 yr of age • early flexion contractures, scoliosis, osteopenia of immobility, increased risk of fracture • death due to pneumonia/respiratory failure or CHF in 2nd-3rd decade Gower’s Sign Child uses hands to “climb up” the legs to move from a sitting to a standing position MG8 Medical Genetics Toronto Notes 2018 c Syndromes and Diseases fre Metabolic Diseases b o k k • inherited disorders of metabolism; often autosomal recessive • infants and older children may present with FTT or developmental delay •organelle disorders can present with dysmorphism universal newborn screening in Ontario includes metabolic disorders Table Metabolic Disorders Carbohydrate Disorders Fatty Acid Disorders Organelle Disorders PKU Tyrosinemia Homocystinuria MSUD Alkaptonuria Urea cycle defects Galactosemia GSDs: von Gierke’s, Pompe’s, Cori’s, Andersen, McArdle MCAD deficiency Carnitine deficiency Mucopolysaccharidosis Congenital disorders of glycosylation Lysosomal storage diseases: Hurler’s, Niemann-Pick, TaySachs, Gaucher, Fabry, Krabbe Clinical Manifestations Irritability, lethargy, poor feeding Seizures Intellectual disability Vomiting and acidosis after feeding initiation Sweet-smelling urine (MSUD) Vomiting and acidosis after feeding initiation Growth retardation, FTT Lethargy, poor feeding Seizures, coma Symptoms triggered by fasting Liver dysfunction Sudden infant death Seizures/early-onset severe epilepsy Chronic encephalopathy Developmental delay Bone crises (Gaucher) Deafness, blindness Laboratory Findings Hypoglycemic hyperammonemia, high anion gap (organic acidemia) Normoglycemic hyperammonemia, normal an on gap (urea cycle defects) Hypoglycemia, hyperlipidemia (GSD) Hypoketotic hypoglycemia Elevated free fatty acids Elevated urine oligosaccharides (oligosaccharidoses) and glycosaminoglycans (mucopolysaccharidoses) Enzyme deficieny Infantile cataracts (galactosemia) Hepatomegaly Muscle weakness/ cramping Hepatomegaly Hypotonia m ks fr Dysmorphic facial features Macrocephaly (Tay-Sachs, Hurler’s) Hepatosplenomegaly (NiemannPick type A/B/C, not Tay-Sachs) Cherry-red spot on macula (Niemann-Pick type A/B, TaySachs, Gaucher’s) Corneal clouding (Hurler’s) Infantile cataract (Fabry) Peripheral neuropathy (Fabry, Krabbe) Spasticity oo eb m Hypotonia/hypertonia Microcephaly, musty odour, eczema, hypopigmentation (PKU) Dark urine, pigmented sclerae, arthralgias (alkaptonuria) Lens subluxation, marfanoid appearance (homocystinuria) fre Physical Exam ee c o s re e c o Examples of Conditions m Organic and Amino Acid Disorders b m eb oo ks ks fre o e co Initial Investigations • important to send lab studies at initial presentation in order to facilitate immediate diagnosis and treatment • check newborn screening results • electrolytes, ABGs (calculate anion gap, rule out acidosis) • CBC with differential and smear • blood glucose (hypoglycemia seen with organic acidemia, fatty acid oxidation defects, and GSDs) • lactate, ammonium (hyperammonemia with urea cycle defects), plasma Ca2+ and Mg2+ • routine urinalysis: ketonuria must be investigated • carnitine levels with acylcarnitine profile • others: urate, urine nitroprusside, plasma amino acid screen, urine organic acids, CSF glycine, free fatty acids (3-β-hydroxybutyrate ratio >4 in fatty acid oxidation defect) • storage diseases: urine mucopolysaccharide and oligosaccharide screen m m Treatment • varies according to inborn error of metabolism • dietary restrictions, supplementation, enzyme replacement therapy, gene therapy, liver transplant, stem cell transplant MG9 Medical Genetics Toronto Notes 2018 c References e PHENYLKETONURIA ks Epidemiology • 1:10,000; autosomal recessive disease b m b bo Etiology • deficiency of phenylalanine hydroxylase prevents conversion of phenylalanine to tyrosine leading to build up of toxic metabolites • mothers who have PKU may have infants with congenital abnormalities bo o ok ok sf re fre e Management • PKU screening at birth • dietary restrict on of phenylalanine starting within the first 10 d of life • duration of dietary restriction controversial – lifelong or until end of puberty; should be resumed during pregnancy to maintain normal phenylalanine levels • large neutral amino acid (tyrosine) replacement, BH4 enzyme treatment, phenylalanine lyase treatment are other options GALACTOSEMIA Epidemiology • 1:60,000; autosomal recessive disease Etiology • most commonly due to deficiency of galactose-1-phosphate uridyltransferase leading to an inability to process lactose/galactose e ee Clinical Presentation • signs of liver and renal failure, jaundice, FTT, and cataracts with ingestion of lactose/galactose k ok s Management • elimination of galactose from the diet (e.g dairy, breast milk) • most infants are fed a soy-based diet m b Complications • increased risk of sepsis, especially E coli • if the diagnosis is not made at birth, liver and brain damage may become irreversible References o re e o sf oo eb eb oo ks fre e e c o Amato RSS Nelson’s essentials of pediatrics, 4th ed Philadelphia: WB Saunders, 2002 Human genetics and dysmorphology 129-146 Blake KD, Prasad C CHARGE syndrome, o phanet J Rare Diseases 2006;1 Biggar W Duchenne muscular dystrophy Pediatr Rev 2006;27:83-88 Chudley AE, Conry J, Cook JL, et al Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis CMAJ 2005;172(5 Suppl):S1-21 Elieff, M P., Lopez-Beltran, A., Montironi, R., & Cheng, L (2008) Familial cancer syndromes In Molecular genetic pathology (pp 449-466) Humana Press Grati, F R., Malvestiti, F Ferreira, J C., Bajaj, K., Gaetani, E., Agrati, C., & Maggi, F (2014) Fetoplacen al mosaicism: potential implications for false-positive and false-negative noninvasive prenatal screening results Genetics in Medicine, 16(8), 620-624 Moeschler JB, Sheve l M Committee on Genetics Comprehensive evaluation of the child with intellectual disability or global developmental delays Pediatrics 2014 Sep;134(3):e903 18 doi:10.1542/peds.2014-1839 Nicholson JF Nelson’s essentials of pediatrics, 4th ed Philadelphia: WB Saunders, 2002 Inborn errors of metabolism 153-178 Sobel, E , & Lange, K (1996) Descent graphs in pedigree analysis: applications to haplotyping, location scores, and marker-sharing statistics American journal of human genetics, 58(6), 1323 Therrell, B L., & Adams, J (2007) Newborn screening in North America Journal of inherited metabolic disease, 30(4), 447-465 Vissers LE, van Ravenswaaij CM, Admiraal R, et al Mutations in a new member of the chromodomain gene family cause CHARGE syndrome Nat Genet 2004 36:955-957 Metabolic disease must be ruled out in any newborn who becomes acut ly ill after a period of normal behaviour and development or with a Reffamily history of early infant death even if the newborn screen is negative co m o Clinical Presentation • baby is normal at birth, then develops a musty odour, eczema, hypertonia, tremors, and mental retardation • hypopigmentation due to low tyrosine (fair hair, blue eyes) sf Notes Toronto Notes 2018 Syndromes and Diseases c MG10 Medical Genetics _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ VS7 Vascular Surgery Toronto Notes 2018 Peripheral Venous Disease fr fr Peripheral Venous Disease o o Deep Venous Thromboembolism b • see Hematology, H35 Varicose Veins m m Definition • distention of tortuous superficial veins resulting from incompetent valves in the deep, superficial, or perforator systems s ok sf re ee e Etiology • primary (99% of cases) varicosities: venous valve incompetence or obstruction ■■ contributing factors: increasing age, systemic hormonal contraceptive use, prolonged standing, pregnancy, obesity • secondary varicosities: DVT, malignant pelvic tumours with venous compression, congenital anomalies, arteriovenous fistulae, trauma m eb bo Epidemiology • primary varicose veins are the most common form of venous disorder of lower extremity 65% of north American adult population gets some degree of venous insufficiency c c m m Clinical Features (often the degree of symptoms not correlate with the clinical findings) • diffuse aching, fullness/tightness, nocturnal cramping ■■ aggravated by prolonged standing (end of day), premenstrual • visible long, dilated and tortuous superficial veins along thigh and leg (great or small saphenous veins and tributaries) • ulceration, hyperpigmentation, and induration (i.e lipodermatosclerosis) ok sf sf r r Complications • recurrent superficial thrombophlebitis/superficial vein thrombosis • features of chronic venous insufficiency: ulceration, eczema, lipodermatosclerosis, stasis dermatitis and hyperpigmentation • bleeding or hematoma secondary to trauma m om m b Treatment • largely a cosmetic problem • conservative: elastic compression stockings • indications for surgery: failure of conservative treatment, symptomatic varix (pain, bleeding, recurrent thrombophlebitis), tissue changes (hyperpigmentation, ulceration), cosmetic • surgical: high ligation and stripping of the long saphenous vein and its tributaries, ultrasound-guided foam sclerotherapy, endovenous laser therapy • 10 year post-operative recurrence of 20% e Chronic Venous Insufficiency s Definition • venous insufficiency and skin damage o bo o o Etiology • calf muscle pump dysfunction and valvular incompetence (reflux) due to phlebitis, varicosities, or DVT • venous obstruction m om Clinical Features • pain (most common), ankle and calf edema – relieved by foot elevation • pruritus, brownish hyperpigmentation (hemosiderin deposits) • stasis dermatitis, subcutaneous fibrosis if chronic (lipodermatosclerosis) • ulceration: shallow, above medial malleolus, weeping (wet), painless, irregular outline • signs of DVT/varicose veins/thrombophlebitis r re e Investigations • not required if conservative treatment only • Doppler U/S (most commonly used in pre-operative assessment) VS8 Vascular Surgery c Lymphedema eb o oo ks ks f Treatment •conservative ■■ elastic compression stockings, ambulation, periodic rest elevation, avoid prolonged standing ■■ ulcers: multilayer compression bandage, antibiotics prn •surgical ■■ if conservative measures fail, or if recurrent/large ulcers to reduce the risk of recurrence ■■ surgical ligation of perforators in region of ulcer (GSV/LSV ligation and stripping) endovenous: laser or radiofrequency ablation or foam sclerotherapy Lymphedema o o Definition • obstruction of lymphatic drainage resulting in edema with high protein content eb s ok sf r Etiology •primary ■■ Milroy’s syndrome: congenital hereditary lymphedema ■■ lymphedema praecox (75% of cases): starts in adolescence ■■ lymphedema tarda: starts >35 yr •secondary ■■ infection: filariasis (#1 cause worldwide) ■■ malignant infiltration: axillary, groin or intrapelvic ■■ radiation/surgery (axillary, groin lymph node removal): #1 cause in North America Clinical Features • classically non-pitting edema • impaired limb mobility, discomfort/pain, psychological distress m e oo ks fr fre co Treatment • avoid limb injury (can precipitate or worsen lymphedema) • cellulitis: treat early to avoid further lymphatic damage • skin hygiene ■■ daily skin care with moisturizers ■■ early medical assessment and treatment for infection (topical for fungal infection; systemic for bacterial infection) • external support ■■ intensive: compression bandages ■■ maintenance: compression garment •exercise ■■ gentle daily exercise of affected limb, gradually increasing ROM ■■ must wear a compression sleeve/bandages when doing exercises • massage: manual lymph drainage therapy Toronto Notes 2018 VS9 Vascular Surgery Toronto Notes 2018 c References fr References m m co m co m m e eb eb o oo Guidelines ACC/AHA guidelines for percutaneous coronary intervention Circulation 2001;103:3019-3041 Beard JD Ch onic lower limb ischemia BMJ 2000;320:854-857 Bell AD, Roussin A, Cartier R, et al The use of antiplatelet therapy in the outpatie t setting: CCS guidelines Can J Cardiol 2011;27:S1-S59 Canadian Cardiovascular Society 2005 Consensus Conference Peripheral Arterial Disease (Draft) Available from: http:// www.ccs.ca CCS focused 2012 update of the CCS atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control Can J Cardiol 2012;28:1 136 European Stroke Organisation, Tendera M, Aboyans V, et al ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric renal, upper and lower extremity arteries Eur Heart J 2011;32(22):2851 2906 Harrington RA, Becker RC, Ezekowitz M, et al Antithrombotic therapy for coronary artery disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy Chest 2004;126(3 suppl):513s-584s May J, White GH, Harris JP The complications and downside of endovascular therapies Adv Surg 2001;35:153-172 Rutherford RB Vascular surgery, 4th ed Toronto: WB Saunders, 1995 Chapter: Atherogenesis and the medical management of atherosclerosis p222-234 Schmieder FA, Comerota AJ Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies Am J Card 2001;87(Suppl):3D-13D Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC) Eur Heart J 2011;32:2851-2906 Way LW, Doherty GM (editors) Current surgical diagnosis and treatment, 11th ed Lange Medical Books/McGraw-Hill, 2004 Yang SC, Cameron DE (editors) Current therapy in thoracic and cardiovascular medicine McGraw-Hill, 2004 eb c m m m co e re sf ok ok sf re e co m m eb eb oo oo ks re ks fre Vascular Surgery Alexander P, Giangola G Deep venous thrombosis and pulmonary embolism: diagnosis, prophylaxis, and treatment Ann Vasc Surg 1999;13:318-327 American College of Cardiology (clinical guidelines, etc) Available from: http://www.acc.org Beard JD Chronic lower limb ischemia BMJ 2000;320:854-857 Bojar RM Manual of perioperative care in cardiac surgery, 3rd ed Massachusetts: Blackwell Sc ence, 1999 Cardiology Online (requires registration) Available from: http://www.theheart.org Cheng DCH David TE Perioperative care in cardiac anesthesia and surgery Austin: Landes Bioscience, 1999 Coulam CH, Rubin GD Acute aortic abnormalities Semin Roentgenol 2001;36:148-164 Crawford ES, Crawford JL, Veith FJ, et al (editors) Vascular surgery: principles and practice, 2nd ed Toronto: McGraw-Hill, 1994 Chapgter: Thoracoabdomina aortic aneurysm Cronenwett JL, Johnston W (editors) Rutherford’s vascular surgery, 7th ed Philadelphia: Saunders/Elsevier, 2014 Freischlag JA, Veith FJ, Hobson RW, et al (editors) Vascular surgery: principles and practice, 2nd ed Toronto: McGraw-Hill, 1994 Chapter: Abdominal aortic aneurysms Fuchs JA, Rutherford RB (editors) Vascular surgery, 4th ed Toronto: WB Saunders, 1995 Chapter: Atherogenesis and the medical management o atherosclerosis p222-234 Hallett JW Jr Abdominal aortic aneurysm: natural history and treatment Heart Dis Stroke 1992;1:303-308 Hallett JW Jr Management of abdominal aortic aneurysms Mayo Clin Proc 2000;75:395-399 Harlan BJ, Starr A, Harwin FM Illustrated handbook of cardiac surgery New York: Springer-Verlag, 1996 Hiratzka LF, Bakris GL, Beckman JA, et al 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease J Am Coll Cardiol 2010;55:e27-e129 May J, White GH, Harris JP The complications and downside of endovascular therapies Adv Surg 2001;35153-35172 Pitt MPI, Bonser RS The natural history of thoracic aortic aneurysm disease: an overview J Card Surg 1997;12(Suppl):270-278 Powell JT, Brown LC The natural history of abdominal aortic aneurysms and their risk of rupture Adv Surg 2001;35:173 185 Rabi D, Clement F, McAlister F, et al Effect of perioperative glucose-insulin-potassium infusions on mortality and atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis Can J Cardiol 2010;26;178-184 Rosen CL, Tracy JA The diagnosis of lower extremity deep venous thrombosis Emerg Med Clin N Am 2001;19:895 912 Schmieder FA, Comerota AJ Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies Am J Cardiol 2001;87(Suppl):3D-13D Veith FJ, Hobson RW, Williams RA, et al Vascular surgery: principles and practices, 2nd ed Toronto: McGraw-Hill, 1994 Verma S, Szmitko PE, Weisel RD, et al Clinician update: should radial arteries be used routinely for coronary artery bypass grafting? Circulation 2004;110:e40-e46 Way LW, Doherty GM Current surgical diagnosis and treatment, 11th ed Lange Medical Books McGraw-Hill, 2004 Yang SC, Cameron DE Current therapy in thoracic and cardiovascular medicine McGraw-Hill, 2004 VS10 Vascular Surgery sf Notes Toronto Notes 2018  _ _ _ _ _ _ o o o _ _ _ _ _ _ _ _ s s s _ _ oo oo oo _ _ _ _ _ _ _ _ _ _ _ _ o o o _ _ _ _ _ _ _ _ _ _ _ _ Index ks e oo ok sf re ks fr e bo c e fre om e c re e c ks o e re sf fr oo co m e ok sf re ok ks Index Androgen Regulation; E45 Anemia; H6, OB25, P40 Chronic Inflammation; H16 Iron Deficiency Anemia; P41 Anesthesia; A2 Angiodysplasia; GS36 Angioedema; D41 Angiography; C14, MI28 Angiography of Gastrointestinal Tract; MI16 Ankle; OR37 Ankylosing Spondylitis; RH21 Anorectal Abscess; GS40 Anorectum; GS38 Anorexia Nervosa; PS31 Antenatal Fetal Surveillance; OB12 Antepartum Care; OB4 Antiarrhythmics; C51 Antibiotics; ID47, ID48 Anticoagulant Therapy; H57 Antidepressants; PS44 Antifungals; ID53 Anti-GBM Disease; NP24 Antimicrobials; ID48 Antiparasitics; ID55 Antiphospholipid Antibody Syndrome; RH12 Antiplatelet Therapy; H56 Antipsychotics; PS42 Antivirals; ID53 Anxiety; ER22 Disorders; PS13, PS36 Anxiolytics; PS48 Aortic Aneurysm; VS5 Aortic Disease; VS4 Aortic Dissection; ER22 Aphasia; N27 Aplastic Anemia; H17 Apnea; P60 Appendicitis; GS27, MI15, P38 Appendix; GS27 Apraxia; N28 Arcus Senilis; OP18 Arrhythmias; C16 Arterial Blood Gases; R5 Arteriovenous Malformat ons; NS23 Arthritis of the Hip; OR29 Articular Cartilage; OR6 Asbestos-Re ated Pleural Disease; R25 Ascending Cholangitis; G43 Ascites; G39 Aspergillus spp.; ID36 Asteatotic Dermatitis; D13 Asthma; ER29, FM16, P82, R7 Astrocytoma; NS13 Atopic Dermatitis; D13 Atrial Fibrillation; N51 Attention Deficit Hyperactivity Disorder; PS38 Atypical Nevus; D9 Auditory Brainstem Response; OT12 Augmentation of Labour; OB37 Aural Rehabilitation; OT12 Autism Spectrum Disorder; PS37 Autoimmune Hemolytic Anemia; H22 Autoimmune Inner Ear Disease; OT20 oo ok bo bo b fr fre m eb oo ks fre om eb oo ks fre eb oo k fre o eb o α-Thalassemia; H20 Abdominal Computed Tomography; MI12 Abdominal Distention; G5 Hernia; GS25 Imaging; MI10 Incisions; GS2 Mass; P39 Pain; ER18, ER59, FM13, P38, G4 Trauma; ER13 X-Ray; MI11 Abnormal Labour; OB37 Abnormal Pseudocholinesterase; A29 Abnormalities Eye Movements; N15 Abnormalities Labour and Delivery; OB37 Visual Field; N15 Aboriginal Legal and Health Policy; ELOM17 Abruptio Placentae; OB14 Acalculous Cholecystitis; GS48 Achilles Tendonitis; OR39 Achilles Tendon Rupture; OR39 Acid-Base Disorders; NP15 Acneiform Eruptions; D11 Acne Vulgaris; D11 Acoustic Neuroma; OT14 Acquired Nevomelanocytic Nevi; D8 Acquired Pigmented Lesions; D9 Acromioclavicular Joint Pathology; OR14 Actinic Keratosis; D33 Acute Arterial Ischemia; VS2 Acute Bacterial Rhinosinusitis; OT25 Acute Blood Transfusion Reactions; H54 Acute Cholangitis; GS49 Acute Cholecystitis; GS47 Acute Confusional State; N20 Acute Coronary Syndrome; ER37 Acute Coronary Syndromes; C27, ER22 Acute Decompensated Heart Failure; ER32 Acute Diarrhea; G15, G4 Acute Epiglottitis; OT44 Acute Kidney Injury; NP18 Acute Laryngitis; OT28 Acute Laryngotracheobronchitis; OT44 Acute Liver Failure; G35 Acute Lymphoblastic Leukemia; H44 Acute Myeloid Leukemia; H37 Acute Otitis Media; P47, FM49 Acute Pain; A24 Acute Pancreatitis; G44, GS51 Acute Pelvic Pain; ER19 Acute Pericarditis; C47, ER22 Acute Psychosis; ER56 Acute Respiratory Distress Syndrome; R27 Acute Rhinitis; FM49 Acute Viral Hepatitis; G28 Acyanotic Congenital Heart Disease; P17 Adenoidectomy; OT40 Adenoid Hypertrophy; OT40 oo A Adenomyosis; GY15 Adhesive Capsulitis; OR15 Adjustment Disorder; PS18 Adolescent Medicine; P15 Adrenal Cortex; E29 Adrenal Gland; GS60 Adrenal Mass; MI18 Adrenal Medications; E52 Adrenal Medulla; E34 Adrenocortical Functional Workup; E30 Adrenocortical Hormones; E29 Adrenocortical Insufficiency; E33 Adrenocorticotropic Hormone; E29 Adult bradycardia algorithm; A32 Adult Polycystic Kidney Disease; NP35 Adult tachycardia algorithm; A32 Advanced Cardiac Life Support Guidelines; A31 Adverse Drug Reactions; CP9 Aesthetic Surgery; PL39 Age-Related Macular Degeneration; OP24 Agnosia; N28 Agoraphobia; PS15 Agranulocytosis; H11 AHA CPR Guidelines; ER5 AIDS; ID27, OP32 Airway Management; A7 Airway Problems in Children; OT42 Alcohol; FM12, PS23 Alcoholic Liver Disease; G34 Alcohol Related Emergencies; ER54 Allergic Reactions; ER28 Allergic Rhinitis; FM14, OT23 Alopecia A eata; D38 Altered Level of Consciousness; ER19 Altered Sensation; N10 Alternative Medicine; FM47 Amaurosis Fugax; OP35 Amblyopia; OP37 Amenorrhea; GY10 American Society of Anesthesiology Classification; A4 Amniotic Fluid Embolus; OB39 Amoebiasis; ID36 Amphetamines; PS25 Amputations; PL26 Amyloidosis; NP24 Amyotrophic Lateral Sclerosis; N35 Anagen Effluvium; D38 Anal Fissures; GS39 Analgesia; A19 Ana gesic and Anesthetic Techniques in Labour; OB33 Analgesic Nephropathies; NP30 Analgesics; A25 Anal Neoplasms; GS42 Anaphylaxis; ER28 Anatomical Triangles of the Neck; OT5 Anatomy of the Eye; OP2 Anatomy of the Neck; OT4 Anatomy of the Thyroid Gland OT5 ANCA-Associated Vasculitis; NP24 and Birth; OB33 Androgenetic Alopecia; D37 Toronto Notes 2018 ks fre ks fre o oo co re sf c e fre e fre fre ks c e re sf ks ks c e fre ks oo ok bo oo e fe Calcaneal Fracture; OR38 Calcium Homeostasis; E36 Canadian Legal Issues; PS50 Cancer Predisposition Syndromes; P46 Candida albicans; ID35 Candidiasis; D31 Cannabis; PS25 Capacity ELOM7 Carcinoma of the Renal Pelvis and Ureter; U22 Cardiac Anatomy; C3 Biomarkers; C11 Catheterization; C14 Infections; ID16 Tamponade; C48, ER22 Transplantation; C38 Cardinal Movements of the Fetus During Delivery; OB32 Carotid Stenosis; N51, VS6 Cataracts; OP20 Catecholamine Metabolism; E34 Catheter Ablation; C25 Catheters; MI10 Cat Scratch Disease; ID24 Cauda Equina Syndrome; NS27 Cavernous; NS23 Celiac Disease; G18, P36 Cellulitis; D26, ID10, FM50 Central Retinal Artery Occlusion; OP22 Vein Occlusion; OP22 Central Venous Access; MI29 Cerebellar Ataxias; N35 Cerebellar Disorders; N34 Cerebral Abscess; NS15 Blood Flow; NS6 Hemorrhage; N52 Cerebral Palsy; P78 Cerebrospinal Fluid Fistulas; NS24 Cerebrovascular Disease; NS18 Cerumen Impaction; OT15 Cervical Cance Screening; FM5 Cervical Disc Syndrome; NS25 Cervical Spine; OR22 Cervical Spondylosis; NS26 Cervix; GY43 Cesarean Delivery; OB42 Cestodes; ID41 Chalazion; OP12 Chemical Burns; OP41 Chemotherapeutic Agents Used in Oncology; H58 Chest Imaging; MI4 Injuries; ER12 Pain; C4, C31, ER21, FM18, R3 Trauma; ER11 X-Ray; MI4, R5 Chiari Malformations; NS38 Child Abuse; ER60, P14 Child Neglect; ER60 Child Psychiatry; PS35 Chlamydia; FM50 Cholangiocarcinoma; GS50 Cholecystitis; MI15 Choledocholithiasis; GS48 Cholelithiasis; GS46 Cholesteatoma; OT17 Chorioamnionitis; OB40 Chronic Abdominal Pain; P39 Arterial Insufficiency; VS3 Arterial Occlusion; VS3 Diarrhea; G5 Kidney Disease NP33 Laryngitis; OT28 Lymphocytic Leukemia; H48 Myeloid Leukemia; H40 Obstructive Pulmonary Disease; R9 Otitis Media; OT17 Pain; A26, NS40 Pancreatitis; G45, GS51 Rhinosinusitis; OT26 Stable Angina; C26 Venous Insufficiency; VS7 Circumcision; P8, U40 Cirrhosis; G36 Clavicle Fracture; OR14 Clinical Approach to Muscle Diseases; N40 Clinical Nutrition; G47 Club Foot; OR44 CNS Infections; ID18, MI21 CNS Tumou s; NS11 Coagulation Factors; H53 Cocaine; PS24 Cold Injuries; ER45 Collateral Ligament Tears; OR32 Colles’ Fracture; OR20 Colonic Pseudo-Obstruction; GS30 Colorectal Cancer Screening; FM4 Colorectal Carcinoma; GS34 Colorectal Neoplasms; GS33 Colorectal Polyps; GS33 Coma; NS35 Common Acne; D11 Common Cold; FM19 Common Infections; ER59 Compartment Syndrome; OR9 Complete Blood Count; H3 Complex Regional Pain Syndromes; N43 Complicated Effusion; R24 ok ks fre oo C oo oo ks fre e bo ok sf re e bo ok sf r c om eb oo ks fr e β-Thalassemia Intermedia; H20 β-Thalassemia Major; H19 β-Thalassemia Minor; H19 Back Pain; ER24, OR23 Bacterial Infections; D25 Bacterial Vaginosis; FM50 Bacteriology; ID2 Bariatric Surgery; GS20 Barrett’s Esophagus; G7 Bartholin Gland Abscess; GY31 Basal Cell Carcinoma; D34 Basal Ganglia; N29 Becker’s Nevus; D9 Bed Bugs; D28 Behavioural Neurology; N20 Benign Active Bone Tumours; OR45 Benign Aggressive Bone Tumours; OR46 Benign Breast Lesions; GS55 Benign Laryngeal Papillomas; OT29 Benign Paroxysmal Positional Vertigo; OT13 Benign Prostatic Hyperplasia; FM17, U7, U43 Bereavement; PS18 Biliary Colic; GS47 Biliary Tract; G40 G3 Binge-Eating Disorder; PS32 Biologic Agents Used in Oncology; H58 Bipolar Disorders; PS12 Bites; ER47 Bladder Carcinoma; U23 Bladder Catheterization; U40 Bladder Trauma; U32 Bleeding Disorders in Neonates; P60 Vaginal; ER40 Blepharitis; OP13 Blood; NS16 Blood and Tissue Infections; ID38 Blood Film Interpretation; H3 Blood Products and Transfusions; H52 Blood Supply to the Face; OT4 Blow-Out Fracture; OP40 Blunt Trauma; OP39 Bone and Joint Infections; ID14 Bone Lesions; MI23 Bone Marrow Aspiration; H5 Bone Marrow Biopsy; H5 Bone Scan; MI28 Bone Tumours Benign Active; OR45 Benign Aggressive; OR46 Botulism; N39 Bowen’s Disease; D35 Brachial Cleft Cysts; OT32 Brachial Plexus; PL4, PL30 Bradyarrhythmias; C18 Brain; MI25 Brain Injury; ER8, NS32 Brainstem; N6 Branch Retinal Artery Occlusion; OP22 k B Branch Retinal Vein Occlusion; OP22 Breast; GS55, PL34 Cancer; GS56 Cance Screening; FM3 Findings; MI31 Imaging; MI30 Interventional Procedures; MI31 Masses; MI31 Breastfeeding and Drugs; OB47 Breath Holding Spells; P8 Breech Presentation; OB22 Brief Psychotic Disorder; PS8 Bronchiectasis; R12 Bronchiolitis; P81 Bronchitis; FM49 Bronchopulmonary Dysplasia; P61 Brown Macule; D5 Bulimia Nervosa; PS31 Bulla; D5 Bullous Pemphigoid; D19 Bunions; OR40 Burns; ER46, PL18 oo ok sf re Autoimmune Liver Disease; G31 Autoimmune Pancreatitis; G46 Autonomic Pharmacology; CP10 Autosomal Recessive Polycystic Kidney Disease; NP36 Toronto Notes 2018 C oo B c A oo Index Index Toronto Notes 2018 c C D ok sf re Diseases of the External Ear; OT15 Diseases of t e Inner Ear; OT19 Diseases of the Middle Ear; OT17 Dislocated Knee; OR34 Dislocated Lens; OP20 Dislocations; PL27 Disorders of Gaze; N15 Disorders of Glucose Metabolism; E6 Disorders of Primary Hemostasis; H27 Disorders of Secondary Hemostasis; H31 Disorders of Sexual Differentiation; U39 Disorders of the Nail Apparatus; D39 Disseminated Intravascular Coagulation; H32 Dissociative Disorders; PS28 Distal Femoral Fracture; OR30 Distal Humeral Fracture; OR16 Disturbances of Alertness and Sleep; N47 Diverticular Disease; GS31 Diverticulitis; GS31, MI15 Diverticulosis; GS31 Dizziness; ER39, FM25, OT6 Domestic Violence; ER28, FM26 Dressings; PL11 Driving Competency; GM11 Drug Biotransformation; CP5 Drug Elimination; CP5 Drug Endings; CP12 Drug Eruptions; D21 Bullous; D22 Exanthematous; D21 Fixed Drug Eruption; D23 Photosensitivity Reaction; D23 Pustular; D22 Urticarial; D22 Drug-Induced Liver Disease; G32 Drug Interactions; CP10 Drug Nomenclature; CP2 Drug Ototoxicity; OT20 Drug Response; CP10 Dry Eye Syndrome; OP10 DSM-5 Diagnostic Criteria ADHD; PS38 Adjustment Disorder; PS18 Agoraphobia; PS15 Anorexia Nervosa; PS31 Bulimia Nervosa; PS31 Delirium; PS19 Delusional Disorder; PS8 Generalized Anxiety Disorder; PS15 Major Depressive Disorder; PS10 Major Depressive Episode; PS9 Major Neurocognitive Disorder; PS20 Manic Episode; PS9 Obsessive-Compulsive Disorder; PS16 Panic Disorder; PS14 Persistent Depressive Disorder; PS11 Post-Traumatic Stress Disorder; PS17 Schizoaffective Disorder; PS8 Schizophrenia; PS6 Sleep-Wake Disorders; PS29 Somatic Symptom Disorder; PS27 Duchenne Muscular Dystrophy; MG7 Duodenum; G3 Dupuytren’s Disease; PL29 Dural Fistulas; NS23 Dyshidrotic Dermatitis; D15 Dyslipidemia; E2 Dyslipidemia Medications; E50 Dyslipidemias; E2, E5 c e r sf ok ks fre e bo fre e co m oo ks ks fr o bo ok sf re e co eb oo ks fre e m eb Dacryoadenitis; OP11 Dacryocystitis; OP11 Dandy-Walker Malformation; NS37 Deep Neck Space Infection; OT46 Deep Vein Thrombosis; ER33 Dehydration; P69 Delayed Blood Transfusion Reactions; H55 Delirium; GM4, N20, PS19 Delivery; OB30 Delusional Disorder; PS8 Dementia; FM20, GM4 Dental Infections; FM49 Dentition and Caries; P9 Depression; FM21, GM4 Depressive Disorders; PS10 Dermatitis; D13 Dermatitis Herpetiformis; D20 Dermatofibroma; D6 Dermatologic Emergencies; ER43 Dermatologic Therapies; D44 Dermatomyositis; RH15 Dermatophytoses; D26 Determinants of Health; PH3 Developmental Dysplasia of the Hip; OR42 Diabetes; NP31, N51 Diabetes Insipidus; E18, NP11 Diabetes Medications; E49 Diabetes Mellitus E7, FM22, OB26, OP33, P25 Diabetic Emergencies; ER34 Diabetic Foot Infections; ID15 Diabetic Ketoacidosis; ER34 Diabetic Nephropathy; E12 Diabetic Neuropathy; E13 Diabetic Renal Complications; NP31 Diabetic Retinopathy; E12, OP33 Dialysis; NP38 Diarrhea; G14, ID13, P34, FM50 Difficult Airway; A9 Difficult Tracheal Intubation; A30 Difficult Tracheal Intubation in Unconscious Patient; A29 Dilated Cardiomyopathy; C40 Dilated Pupil; OP30 Diplopia; N16, OP4 Discrete Red Papule; D5 Disease Prevention; PH5 Diseases of Airway Obstruction; R7 Diseases of Hair Density; D37 oo o D bo ok sf re e co m bo bo ok sf re Cryptococcus spp ID35 Cryptorchidism; GS64 Cryptosporidium spp.; ID37 Crystal-Induced Arthropathies; RH25 C-spine; ER10 CT Head; MI19 Cushing’s Syndrome; E32 Cutaneous Cancers; D36 Cutaneous T-Cell Lymphoma; D36 Cyanosis; P62 Cyanotic Congenital Heart Disease; P19 Cystic Diseases of the Kidney; NP35 Cystic Fibrosis; P82, R12 Cystitis; U13 Cystoscopy; U41 Cysts; D5 oo oo ks fre bo ok sf re e co eb oo ks ee eb oo ks fre e c eb oo ks fre Complications of Hematologic Malignancies; H51 Complications of Labour and Delivery; OB37 Complications of Pregnancy; ER41 Complications of Wrist Fractures; OR21 Computed Tomography Chest; MI6 Concussion; FM20 Conduct Disorder; PS39 Confidentiality; ELOM6 Congenital Anomalies; MG4 Congenital Diaphragmatic Hernias; GS62 Congenital Glaucoma; OP39 Congenital Hand Anomalies; PL40 Congenital Heart Disease; P16 Congenital Neck Masses; OT32 Congenital Nevomelanocytic Nevi; D8 Congenital Pigmented Lesions; D8 Congenital Sensorineural Hearing Loss; OT19 Congenital Talipes Equinovarus; OR44 Congestive Heart Failure; C34, P20 Conjunctiva; OP13 Conjunctivitis; OP14 Connective Tissue Disorders; OP35, RH8 Conscientious Objection; ELOM17 Consent; ELOM7 Constipation; G24, P37, G5 Constricted Pupil; OP30 Constrictive Pericarditis; C48 Contact Dermatitis; D14 Contraception; FM20, GY17 Contrast Enhancement; MI4 Contrast Studies; MI13 Conversion Disorder; PS28 Coordination Exam and Gait; N5 COPD; FM16 Cord Injury; ER10 Cornea; OP16 Corneal Abrasion; OP16 Corneal Ulcer; OP17 Corns; D7 Coronary Angiography; C15 Coronary Angiography, Contrast-Enhanced CT; C16 Coronary Artery Disease; A5 Coronary Circulation; C2 Coronary Revascularization; C31 Cough; FM20, R3 Counselling of the Pregnant Woman; OB9 Coxa Plana; OR43 Cranial Nerve Deficits; N11 CN I: Olfactory Nerve; N11 CN II: Optic Nerve; N11 CN III: Oculomotor Nerve; N11 CN IV: Trochlear Nerve; N12 CN V: Trigeminal Nerve; N12 CN VI: Abducens Nerve; N12 CN VII: Facial Nerve; N12 CN VIII: Vestibulocochlear Nerve; N13 CN IX: Glossopharyngeal Nerve; N13 CN X: Vagus Nerve; N13 CN XI: Accessory Nerve; N13 CN XII: Hypoglossal Nerve; N13 Cranial Nerve Exam; N3 Craniofacial Anomalies; PL39 Craniofacial Injuries; PL31 Craniosynostosis; NS38 Creutzfeldt-Jakob Disease; N27 Crohn’s Disease; G20, G19 Cruciate Ligament Tears; OR32 Crying/Fussing Child; P8 Cryoglobulinemia; NP24 ks f oo e ks fre co e fre e fre m e fre c ee Gait Disturbance; N10 Galactosemia; MG9 Galeazzi Fracture; OR20 Gallbladder Carcinoma; GS50 Gallstone Ileus; GS49 Gastritis; G11 Gastroenteritis; P35 Gastroesophageal Reflux Disease; G6, ER22 Gastrointestinal Bleeding Lower; P40 Gastrointestinal Infections; ID11 Gastrointestinal Stromal Tumour; GS20 Gastrointestinal Tract; G2, G4 Gastroschisis; GS63 Gender Dysphoria; PS30 Generalized Anxiety Disorder; PS15 Generalized Edema; C5 Generalized Tetanus; ID20 Genetic Counselling; MG3 Genetics; MG2 Genetic Syndromes and Diseases; MG5 Genetic Testing; MG3 Genitourinary System; MI16 Genitourinary Tract Injuries; ER14 Geriatric Pharmacology; GM15 Gestational Age; P58 Gestational Trophoblastic Disease; GY49 Giant Cell Arteritis; OP35, RH20 Giardia lamblia; ID37 Gilbert’s Syndrome; G41 Glasgow Coma Scale; ER4 Glaucoma; OP25 Global Developmental Delay; P22 Globe Displacement; OP9 Glomerular Diseases; NP19 Glomerular Syndromes; NP22 Glucose-6 Phosphate Dehydrogenase Deficiency; H23 Gonococcemia; D32 Gonorrhea; FM50 Gout; RH25 Graves’ Disease; E23, OP35 Groin Hernias; GS27 Group B Streptococcus; OB27 Growing Pains; P84 Growth and Development; P4, P26 Growth Hormone; E16 Gynecological Imaging GY8, MI17 Gynecological Infections; GY26 Gynecological Oncology; GY38 Gynecomastia; E47, PL37 ks m re sf sf re sf G ks m ks fre ok Spine; NS34 Frailty; GM2 Freckles; D9 Frostbi e; ER46 Frozen Shoulder; OR15 Functional Neurosurgery; NS39 Functional Renal Imaging; MI27 Funding, Health Care; ELOM4 Fungal Infections; ID33 oo ok sf re bo oo Facial Nerve Paralysis; OT4, OT22 Factor XI Deficiency; H32 Failure to Thrive; P10 Fallopian Tube; GY48 Falls; GM4 Familial Cancer Syndromes; MG7 Familial Colon Cancer Syndromes; GS33 Fasting Guidelines; A6 Fatigue; FM30 Febrile Infant; ER58 Febrile Neutropenia; ID45 Febrile Seizures; ER58, P77 Femoral Diaphysis Fracture; OR30 Femur; OR30 Fetal Alcohol Spectrum Disorder; P24 Fetal Monitoring in Labour; OB33 Fetal Movements; OB12 Fever; FM31, P46 Fever in the Returned Traveller; ID42 Fever of Unknown Origin; ID44 Fibroadenoma; GS55 Fibroids; GY15 Fibromyalgia; RH28 Fibrous Lesions; D6 First Trimester Bleeding; GY8 Fistula; GS37 Fistulae; OT32 Fistula-In-Ano; GS40 Flatworms; ID41 Floaters; OP4 Fluid Balance; A13 Folate Deficiency; H25 Follicle Stimulating Hormone; E17 Food Intake Disorder; PS32 Foot; OR38 Forceps; OB41 Forearm; OR19 Foreign Body; OP16, OT45 Four Stages of Labour; OB32 Fractures; OR4, PL27 Children; OR41 Open; OR8 ok Toronto Notes 2018 G F ok oo ks f bo ok sf re e co bo ok sf re e bo ok sf Ear Anatomy; OT2 Eating Disorders; PS30 ECG Changes; ER23 Echocardiography; C12 Eclampsia; OB25 Ectopia Lentis; OP20 Ectopic Pregnancy; GY21 Ectopic Testes; U38 Ectropion; OP12 Eczema; D13 Elbow; OR17 Elbow Dislocation; OR18 Elder Abuse; FM26, GM10 Electrical Pacing; C24 Electrocardiography; C5 Electrolyte Disorders; NP7 Electrolyte Disturbances; ER36 Electrolytes; P69 Electrophysiology Studies; C24 Elevated ICP; NS6 Elevated Triglycerides; E3 Embolization; MI28 Emergency Postcoital Contraception; GY19 Empyema; R24 Encephalitis; ID19 Encopresis; P10 Endemic Mycoses; ID33 Endocrine Organs; E2 End-of-Life Care; ELOM14, GM13 Endometrial Biopsy; GY9 Endometrial Carcinoma; GY38 Endometriosis GY13 Endophthalmitis; OP21 End Stage Renal Disease; NP37 Entamoeba histolytica; ID36 Enteral Nutrition; G47 Enteropathic Arthritis; RH23 Entropion; OP12 Enuresis; P9 Environmental Health; PH20 Environmental Injuries; ER45 Eosinophilia; H11 Ephelides; D9 Epidemiology; PH8 Epididymitis; U16 Epidural; A20 Epilepsy; N18, NS41 Epiphora; OP10 Epiphyseal Injury; OR41 Episcleritis; OP15 Episiotomy; OB42 Epistaxis; ER40, OT26 bo E F Erectile Dysfunction; FM29, U30, U42 Erysipelas; D26, PL15 Erythema Nodosum; D42 Erythrocytosis; H6 Esophageal Diverticula; G9 Esophageal Motor Disorders; G8 Esophageal Rupture; ER22 Esophageal Varices; G26 Esophagitis; ER22 Esophagus; G3 Essential Thrombocythemia; H43 Ethics, Principles of; ELOM5 Evaluation of the Dizzy Patient; OT12 Excision; PL7 Exercise; FM10 Exostoses; OT16 Experimental Study Designs; PH13 Extracorporeal Shock Wave Lithotripsy; U42 Extracranial Pathology; NS24 Extradural (“Epidural”) Hematoma; NS17 Extradural Lesions; NS24 Extubation; A20 bo bo ok sf re Dysmenorrhea; GY6 GY13 Dysmorphic Child; MG4 Dysmorphisms; MG4 Dyspareun a; GY8 Dyspepsia; FM27, G5 Dysphagia; G5 Dysplasia of the Hip; OR42 Dyspnea; C5, FM27, P79, R3 Dysrhythmias; P20 Dystocia; OB37 Dystonia; N33, NS39 Dysuria; FM28, U10 E oo D oo Index ks fe Idiopathic Myelofibrosis; H42 Idiopathic Pu monary Fibrosis; R14 Ileum; G3 Illness Anxiety Disorder; PS27 Imaging Modalities; MI2 Immobility; GM9 Immune Reconstitution Syndrome; ID46 Immune Thrombocytopenia; H27 Immune Thrombocytopenic Purpura; P42 Immunizations; GM11 Immunogenetics and Disease; RH2 Immunology; RH2 Impaired Glucose Tolerance; E6 Impedance Audiometry; OT11 Impetigo; D25 Implantable Cardioverter Defibrillators; C24 Incontinence; GM8 Induction Agents; A16 Induction Methods; OB37 Induction of Labour; OB36 Infantile Colic; P8 Infected Wounds; PL9 Infection Control Targets; PH20 Infections During Pregnancy; OB29 Infections in Gynecological Surgery; GY33 Infections in Solid Organ Transplant Recipients; ID46 Infections in the Immunocompromised Host; ID45 Infections (skin); D25 Infectious Esophagitis; G9 Infectious Mononucleosis; P52 Infectious Pediatric Exanthems; P50 Infectious Pharyngitis; P52 Infective Endocarditis; ID16, NP25 Inferior Vena Cava Filter; MI29 Infertility; E45, GY23, U34 Inflammatory Bowel Disease; G19, GS28 Influenza; ID9 Inhalation Injury; ER47 Initial Prenatal Visit; OB4 Injury Prevention Counselling; P7 Insect Bites; ER48 Insulin Regimens; E10 Intellectual Disability; P22 Intensive Care; R33 Intermittent Explosive Disorder; PS40 Internuclear Ophthalmoplegia; N15 Interstitial Cystitis; U14 Interstitial Lung Disease; R13 Interventional Radiology; MI28 Intestinal Atresia; GS63 Intestinal/Genitourinary Infections; ID36 Intestinal Ischemia; GS23 Intracerebral Hemorrhage; NS22 Intracranial Aneurysms; NS20 Intracranial Pathology; NS4 Intracranial Pressure Dynamics; NS4 Intraductal Papilloma; GS55 Intradural Intramedullary Lesions; NS29 Intraoperative Management; A12 Intrauterine Fetal Death; OB18 Intrauterine Growth Restriction; OB19 Intraventricular Hemorrhage; P63 Intubation Unconscious Patient, Tracheal; A29 Intussusception; GS64 Iron and Folate Deficiency Anemia; OB25 Iron Deficiency Anemia; H15 Iron Metabolism; H13 ok sf re e o bo e re sf co re sf ok o bo eb oo ks fr c eb bo ok m ee ks oo c bo oo ks fre e eb fre ks ks Ichthyosis Vulgaris; D23 ICP Measurement; NS6 ICP/Volume Relationship; NS5 Idiopathic Inflammatory Myopathy; RH15 Idiopathic Intracranial Hypertension; NS8 oo fre c I oo ok s e o eb oo ks eb oo k fr c e eb oo k fre e eb oo k Hair Follicle Infections; D26 Hair Growth; D37 Hallucinogens; PS26 Hand Anatomy; PL2 Hand Infections; PL25 Hand Injuries; PL23 Hashimoto’s Thyroiditis; E27 Hay Fever; OT23 Hazards of Hospitalization; GM10 Headache; ER23, FM32, N44 Head Injury; NS32 Head Trauma; ER7 Health Care System; ELOM2 Health Promotion; FM6 Health Services Research; PH17 Hearing; OT9 Hearing Impairment; FM33 Hearing Loss; ER39, OT7 Hearing Loss; OT9 Heart Failure; C34 Heart Murmurs; P21 Heat Exhaustion; ER45 Heat Stroke; ER45 Heel Spur Syndrome; OR39 Helminths; ID40 Helomata; D7 Hemangiomas; D9 Hematologic Malignancies; H37 Hematoma Blocks; A23 Hematopoiesis; H2 Hematuria; NP2 U4 Hemiptera; D28 Hemochromatosis; G33 Hemolytic Anemia; H18 Hemolytic Uremic Syndrome; H30, P71 Hemophilia A; H31 Hemophilia B; H31 Hemoptysis; R3 Hemorrhoids; GS38 Hemostasis; H25 Henoch-Schönlein Purpura; NP24, P86 Hepatic Encephalopathy; G38 Hepatitis A; G29 B; G29, NP25 C; G30, NP25 D; G30 Hepatobiliary Disease; G28 Hereditary El iptocytosis; H23 Hereditary Spherocytosis; H22 Heritable Disorders; D23 Hernia Diaphragmatic; P62 Inguinal; GS64 Herniation Syndromes; NS7 Herpes; FM50 Herpes Simplex; D29 Herpes Simplex Keratitis; OP17 Herpes Simplex Virus of Vulva; GY29 Herpes Zoster; D29, ER22 Herpes Zoster Ophthalm cus; OP18 HIDA Scan; MI27 Hip; OR27 Hip Dislocation; OR27 Hip Dislocation Post-Total Hip Arthroplasty; OR29 Hip Fracture; OR28 Hirschsprung’s Disease; GS64 HIV; ID27, OP32 HIV-Associated Renal Disease; NP25 Hoarseness; OT8 Hodgkin Lymphoma; H45 Hordeolum; OP12 Hormone Replacement Therapy; FM40, GY35 H pylori-Induced Peptic Ulceration; G13 Human Papillomavirus; GY29 Human Papillomavirus Infections; D30 Humeral Shaft Fracture; OR16 Humerus; OR15 Huntington’s Disease; N33 Hydrocele; GS62 Hydrocephalus; NS9 Hydrocephalus in Pediatrics; NS37 Hydronephrosis; U10 Hyperandrogenism; E32 Hypercalcemia; E37 Hypercapnic Respiratory Failure; R26 Hypercholesterolemia; E4, N51 Hypercoagulable Disorders; H33 Hyperemesis Gravidarum; OB5 Hypergonadotropic Hypogonadism; E18 Hyperkalemia; NP13 Hyperkeratotic Lesions; D6 Hypermagnesemia; NP15 Hypernatremia; NP10 Hyperosmolar Hyperglycemic State; ER35 Hyperparathyroidism; MI25 Hyperphosphatemia; NP14 Hypersensitivity Pneumonitis; R15 Hypertension; A5 FM34, GM6, NP35, N51, OP34 Hypertension Childhood; P74 Emergencies; ER36 Nephrosclerosis; NP35 Pregnancy; OB23 Hypertensive Disorders of Pregnancy; OB23 Hyperthyroidism; P28 Hypertriglyceridemia; E3 Hypertrophic Cardiomyopathy; C41 Hypertrophic Pyloric Stenosis; GS62 Hyperviscosity Syndrome; H51 Hyphema; OP40 Hypocalcemia; E39 Hypoglycemia; ER35, E14, P63 Hypogonadism; E45 Hypokalemia; NP11 Hypomagnesemia; NP15 Hyponatremia NP8 Hypophosphatemia; NP14 Hypopituitarism; E19 Hypothermia; ER45 Hypothyroidism; E26, P28 Hypotonia; P78 Hypoventilation Syndromes; R32 Hypoxemic Respiratory Failure; R26 Hysterectomy; GY9 oo H Toronto Notes 2018 I fre H ok Index e co m ok sf re m co e ks fre e om m oo m e re m co fre fre re sf Macrocytic Anemia; H23 Macrosomia; OB19 Magnetic Resonance Imaging; C16, MI3 Major Depressive Disorder; NS40 Major Neurocognitive Disorder; N21, PS20 Malabsorption; G16 Malaria; ID38 Maldigestion; G16 Male Reproductive Endocrinology; E45 Malformations; NS23, OT34 Malignant Bone Tumours; OR47 Malignant Clonal Proliferations of Mature B-Cells; H48 Malignant Hyperthermia; A28 Malignant Melanoma; D35 Malignant (Necrotizing) Otitis Externa; OT16 Malignant Skin Lesions; PL5 Malignant Skin Tumours; D34 Malignant Vulvar Lesions; GY47 Mallampati Classification; A3 Mallory-Weiss Tear; G26 Malnutrition; GM6 Malpresentation; OB21 Malrotation; GS63 Mammalian Bites; ER47 Mammography; FM4, MI30 fre ks fr m e ok sf re M sf ok ee bo ok s re e bo ok s Labour; OB30 Abnormalities; OB37 Complications of Labour and Delivery; OB37 Lacerations; OB42 Lacrimal Apparatus; OP10 Lactose Intolerance; P36 Lambert-Eaton Myasthenic Syndrome; N39 Language Delay; P23 Large Bowel; G3 Bowel Obstruction; GS29 Genomic Changes; MG5 Vessel Disease; NP28 Vessel Vasculitis; RH20 Laryngomalacia; OT45 Lead Poisoning; H17 Legg-Calvé-Perthes Disease; OR43 Lens; OP20 Leopold’s Maneuvers; OB6 Leprosy; ID22 Leukemia; P44 Leukemoid Reaction; H12 Leukocoria; OP38 Leukoplakia; D33 Lice; D28, FM50 Lichen Planus; D16 Lichen Simplex Chronicus; D16 Lid Carcinoma; OP31 Lid Swelling; OP11 Life- and Limb-Threatening Injuries; ER15 Life-Threatening ECG Changes; ER23 Limb Pain; P83 Lines; MI10 Lipid Transport; E2 ok L ks bo Kawasaki Disease; P87 Kayser-Fleischer Ring; OP18 Keloids; D7 Keratoacanthoma; D35 Keratoconjunctivitis Sicca; OP10 Keratoconus; OP18 Kidney Functions; NP2 Knee; OR31 ks K bo c Jaundice; P64, G6 Jejunum; G3 Joint Pain; ER24, FM37, RH3 Joint Pathology; RH2 Juvenile Idiopathic Arthritis; P85 Mandibular Fractures; PL31 Mastitis; FM50 Mastoiditis; OT18 Mastopexy; PL36 Maternal Physiologic Adaptations to Pregnancy; OB3 Maxillary Fractures; PL32 Meckel’s Diverticulum; GS62 Meconium; OB40 Mediastinal Abnormalities; MI9 Mediastinal Masses; R21 Mediastinitis; R22 Medical Complications of Pregnancy; OB25 Medium Vessel Disease; NP29 Medium Vessel Vasculitis; RH19 Medullary Sponge Kidney; NP36 Melasma; D9 Ménière’s Disease; OT13 Meningioma; NS13 Meningitis; ID18, P54 Meniscal Tears; OR33 Menopause; FM40, GY34 Menstrual Cycle; GY4 Mental Status; N3 Mental Status Exam; PS3 Mesothelioma; R25 Metabolic Acidosis; NP16 Metabolic Alkalosis; NP17 Metabolic Bone Disease; E40, MI24 Metabolic Bone Disease Medications; E51 Metabolic Diseases; MG8 Metastatic Bone Tumours; MI23 Metastatic Tumours; NS12 Metatarsal Fracture; OR40 Microangiopathic Hemolytic Anemia Thrombotic Microangiopathy; H22 Microbiology; ID2 Microcytic Anemia; H13 Migraine Headaches; N45 Mild Neurocognitive Disorder; N21 Mild Traumatic Brain Injury; ER9, FM20, N28 Milk Allergy; P36 Mineralocorticoid Excess Syndromes; E31 Miosis; OP30 Modified Glasgow Coma Score; ER57 Molluscum Contagiosum; D30 Monitoring; A6 Monoclonal Gammopathy of Unknown Significance; H51 Monteggia Fracture; OR19 Mood Disorders; PS9, PS36 Mood Episodes; PS9 Mood Stabilizers; PS47 Motor Exam; N4 Motor Neuron Disease; N35 Movement Disorders; N29, N31, NS39 Multi-Fetal Gestation; OB21 Multiple Endocrine Neoplasm; E35 Multiple Myeloma; H49, NP33 Multiple Sclerosis; MI20, N52, OP34 Mumps; P55 Muscle Relaxants; A17 Musculoskeletal; ER22 Musculoskeletal System; MI21 Myasthenia Gravis; N38 Mycology; ID5 Mydriasis; OP30 Myelodysplastic Syndromes; H39 ks ok sf Lipoma; D10 Liver; G28, G3 Liver Abscesses; GS43 Liver Cysts; GS43 Liver Disease; H32 Liver Transplantation; GS45 Local Anesthetic Agents; A22 Local Edema; C4 Local Infiltration; A23 Loss of Consciousness; C4 Loss of Vision; OP3 Low Back Pain; FM38 Lower Gastrointestinal Bleeding; G27 Lower GI Bleed; G5 Lower Limb Ulcers; PL16 Lower Respiratory T act Diseases; P80 Lower Urinary Tract Dysfunction; U5 Lower Urinary Tract Symptoms; U6 Low High-Density Lipoprotein; E4 Lumbar Disc Syndrome; NS26 Lumbar Puncture; N9 Lumbar Spinal Stenosis; NS28 Lund-Browder Diagram; PL19 Lung Abnormalities; MI6 Lung Cancer; R28 Lung Cancer Screening; FM4 Luteinizing Hormone; E17 Lyme Arthritis; P86 Lyme Disease; ID23 Lymphadenopathy; H12, P43 Lymphedema; VS8 Lymphocytosis; H10 Lymphoid Malignancies; H44 Lymphomas; H45 P44 Lymphopenia; H11 Lymphoplasmacytic Lymphoma; H51 oo J Toronto Notes 2018 M oo L bo ok sf re Irritable Bowel Syndrome; G23 Ischemic Heart Disease; C25 Ischemic Stroke; N50 “itis” Imag ng; MI15 IV Fluids; A14 K oo J ok Index Osgood-Schlatter Disease; OR43 Osteoarthritis FM40, RH5 Osteomalacia; E42, MI24 Osteomyelitis; MI23, OR9, P85 Osteopenia; MI24 Osteoporosis; E40, FM41, MI24 Otalgia; ER39, OT6 Other Parkinsonian Disorders; N32 Otitis Externa; FM49 Otitis Media with Effusion; OT39, P49 Otoacoustic Emissions; OT12 Otosclerosis; OT18 Ottawa SAH Rule; ER23 Outbreak of Infectious Diseases; PH18 Ovarian Tumours; GY40 Overactive Bladder; U11, U43 c ee f eb oo ks fre Non-Hodgkin Lymphoma; H46 Non-Melanoma Skin Cancers; D34 Non-Scarring Alopecia; D37 Non-Toxic Goitre; E28 Nonvascular Interventions; MI29 Normal Hearing Physiology; OT9 Normal Labour and Delivery; OB30 Normal Tension Glaucoma; OP26 Normocytic Anemia; H17 Nosocomial Infections; ID6 NSAID-Induced Ulceration; G13 Nuclear Medicine; MI25 Numbness; N10 Nummular Dermatitis; D15 Nutrition; FM6, P6 Deficiencies; N17 Status; G47 Nystagmus; N16 P bo e re sf ok co e fre sf fr ks co re sf ok Paget’s Disease; MI25 Paget’s Disease of Bone; E44 Painful Diabetic Neuropathy; N43 Painless Vision Loss; OP4 Pain Management; A24 Pain Syndromes; N41 Palliative Care; GM13 Palpitations; C5 Pancreas; G43, G3, GS51 Pancreatic Cancer; GS52 Pancreatic Enzyme Abnormalities; G43 Pancreatitis; MI15 Pancytopenia; H8 Papulosquamous Diseases; D16 Paralytic Ileus; GS23 Paraneoplastic Syndrome; E48 Paraphilic Disorders; PS30 Parasitic Infections; D27, ID36 Parasitology; ID5 Parathyroid; GS60 Parenchymal Kidney Diseases; NP19 Parenteral Nutrition; G48 Parkinson’s Disease; N32, NS39 Parotid Gland Neoplasms; OT31 Patella; OR34 Patellar Dislocation; OR35 Patellar Fracture; OR34 Patellar Tendon Rupture; OR33 Patellofemoral Syndrome; OR35 Pathology of Aging; GM2 Patient Assessment; ER2 Pediatric Anesthesia; A27 Brain Tumours; NS39 Neurosurgery; NS36 Ophthalmology; OP36 Orthopedics; OR41 Otolaryngology; OT38 Plastic Surgery; PL39 Renal Diseases; P71 Surgery; GS62 Urology; U36 Vitals; P3 Pediculosis; D28 Pelvic bo ok sf re Obesity; FM7, P11 Obsessive Compulsive Disorder; NS40 Obsessive-Compulsive Disorder; PS16 Obstetrical Anesthesia; A26 Obstetrical Complications; OB15 Obstetrical Hemorrhage; OB13 Occupational Health; PH23 Ocular Drug Toxicity; OP41 Emergencies; OP5 Examination; OP5 Manifestations of Systemic Disease; OP32 Pain OP4 Pain Syndromes; N41 Trauma; OP39 Odynophagia; G5 Olecranon Fracture; OR18 Oligohydramnios; OB20 Omphalocele; GS63 Open Fractures; OR8 Operative Obstetrics; OB41 Operative Vaginal Delivery; OB41 Ophthalmia Neonatorum; OP39 Ophthalmologic Emergencies; ER42 Foreign Body; ER42 Opioids; A25 PS24 Opportunistic Fungi; ID34 Oppositional Defiant Disorder; PS39 Optic; OP7 Disc Atrophy; N14 Disc Edema; N14 Oral Ulcer; D5 Orbit; OP9 Orbital Cellulitis; OP9 Floor Fractures; PL33 Orchitis; U16 Organ Failure; R33 Orthopedic Emergencies; OR8 Orthopedic Emergencies; OR8 Injuries; ER15 X-Ray Imaging; OR7 oo bo O ks ks fre e bo ok sf re e o eb oo ks f c b ok fre Nails; D39 Nasal Anatomy; OT3 Nasal Fractures; PL32 Nasal Obstruction; OT8 Nasolacrimal System Defects; OP39 Nausea; OB4 Nausea/Vomiting; G5 NCD Frontotemporal; N25 Alzheimer’s Disease; N23 Lewy Bodies; N25 Vascular; N26 Near Drowning; ER48 Neck Mass; OT9 Neck Masses; OT31 Necrotizing Enterocolitis; P66 Necrotizing Fasciitis; ID10, PL15 Neglect; P14, P15 Negligence; ELOM10 Nematodes; ID40 Neonatology; P58 Neoplasia; GY49 Neoplasms; GS44, R28 Neoplasms of the Head and Neck; OT34 Nephritic Syndrome; P72 Nephroblastoma; P45, U38 Nephrolithiasis; ER42 Nephrotic Syndrome; P73 Neuroblastoma; P45 Neurocognitive Disorders; PS19 Neurocutaneous Syndromes; P79 Neurodevelopmental Disorders; PS37 Neurofibromatosis; D24 Neurogenic Bladder; U9 Neurogenic Claudication; NS28 Neurological Comp aint Lesion Localization; N2 Neurological Exam; N3 Neurologically Determined Death; NS35 Neuromuscular Junction Diseases; N38 Neuro-Oncology; N29 Neuro-Ophthalmology; N14 Neuropathic Pain; N41 Neuropsychiatric Disorders; NS40 Neuroradiology; MI18 Neurotrauma; NS30 Neutrophilia; H9 Nevomelanocytic Nevi; D8 Nightstick Fracture; OR20 Nipple Areolar Complex Reconstruction; PL38 Noise-Induced Sensorineural Hearing Loss; OT21 Non-Alcoholic Fatty Liver Disease; G35 Non-Articula Rheumatism; RH27 Toronto Notes 2018 P b N O bo eb oo ks fre Myeloid Malignancies; H37 Myeloproliferative Neoplasms; H40 Myocardial Disease; C39 Myocardial Perfusion Scanning; MI26 Myocarditis; C39 Myopathies; N40 Myotonic Dystrophy; N41 Myxedema Coma; E27 N ok sf re M bo Index oo ks fre Pupil Abnormal ties; OP28 Pupillary Light Reflex; OP28 Pupils; OP28 Pure Tone Audiometry; OT10 Pustule; D5 Pyelonephritis; U14 Q m Quadriceps Tendon Rupture; OR33 Qualitative; PH11 Quantitative; PH11 R ks fre e o oo Rabies; ID20 Radial Head Fracture; OR17 Radical Prostatectomy; U41 Radionuclide Ventriculography; MI27 Radius Fractures; OR19 Rapid Primary Survey; ER2 Rapid Sequence Induction; A15 Rashes; P12 RBC Scan; MI27 Reactive Arthritis; P86, RH24 Reconstruction Ladder; PL12 Rectal Prolapse; GS41 Recurrent Erosions; OP16 Recurrent Headache; P77 Red Blood Cells; H3, H52 Red Eye; OP3 Red Scales; D5 Regional Anesthesia; A20 Relative Afferent Pupillary Defect; OP31 Renal Colic; ER42 Function; NP5 Hemodynamics; NP4 Mass; U20 Neoplasms; U20 Osteodystrophy; E43 Parenchymal Hypertension; NP35 Replacement Therapy; NP38 Stones; U18 Structure and Function; NP2 Transplantation; NP39 Trauma; U32 Repor able Diseases; PH24 Research Ethics; ELOM16 Resource Allocation; ELOM16 Respiratory Diseases; A5 Respiratory Distress; ER57 Respiratory Distress in the Newborn; P67 Respiratory Failure; R26 Respiratory Infections; ID7 Respiratory Tract Diseases; P80 Restrictive Cardiomyopathy; C42 Resuscitation; A13, ER4 Retained Placenta; OB44 Retina; OP2, OP22 Retinal Detachment; OP23 Retinitis Pigmentosa; OP23 Retinoblastoma; OP38 e c fr ks m co e fre ks sf re e co bo ok sf e c bo ok sf r e co bo ok sf re co bo ok sf re Positron Emission Tomography Scans; MI3 Posterior Vitreous Detachment; OP21 Postherpetic Neuralgia; N42 Post-Obstructive Diuresis; U11 Post-Operative Care; A23 Postpartum Care; OB46 Postpartum Hemorrhage; OB43 Postpartum Mood Alterations; OB46 Postpartum Mood Disorders; PS12 Postpartum Pyrexia; OB45 Postterm Pregnancy; OB18 Potassium Homeostasis; NP11 Powers of Attorney; ELOM10 PQRSTU Approach to ECGs; C9 Preconception Counselling; OB4 Pre-Diabetes; E6 Preeclampsia; OB24 Pre-Excitation Syndromes; C21 Pregnancy; OB2 Pre-Malignant Skin Conditions; D33 Premature Rupture of Membranes; OB17 Premenstrual Dysphoric Disorder; GY5 Premenstrual Syndrome; GY5 Prenatal Screening and Diagnostic Tests; OB6 Presbycusis; OT19 Preseptal Cellulitis; OP9 Pressure Ulcers; GM9, PL17 Preterm Labour; OB15 Primary Angle-Closure Glaucoma; OP27 Biliary Cholangitis; G42 Care Models; FM48 Morphological Lesions; D3 Open-Angle Glaucoma; OP26 Sclerosing Cholangitis; G41 Principles of Family Medicine; FM2 Professional Conduct; ELOM15 Prolactin; E17 Prolapse; GY37 Prostate Cancer; U25 Prostate Cancer Screening; FM5, U26 Prostatic Carcinoma; U43 Prostatitis; U15 Prostatodynia; U15 Proteinuria; NP20 Protozoa; ID36 Proximal Humeral Fracture; OR15 Pruritus; D42, GY6 Pseudogout; RH26 Psoriasis; D17 Psoriatic Arthritis; RH23 Psychiatric Assessment; PS2 Psychiatric Emergencies; ER56 Psychosis; PS6 Psychotherapy; PS40 Psychotic Disorders; PS6 Pterygium; OP13 Ptosis; OP11 Public Health; PH2 Public Health Services; PH2 Puerperal Complications; OB43 Pulmonary Embolism; ER33, ER22 Pulmonary Function Tests; R4 Pulmonary Hypertension; R17 Pulmonary Hypertension of the Newborn; P67 Pulmonary Vascular Abnormalities; MI8 Pulmonary Vascular Disease; R17 Pulmonary Vasculitis; R21 ok ok sf re e o eb oo ks fre e bo ok sf re bo ok sf re e m eb oo k fr Fracture; OR26 Inflammatory Disease; GY31 Mass; GY7 Pain; GY7 Pelvis; OR26 Pemphigus Vulgaris; D20 Penetrating Trauma; OP40 Penile Complaints; U30 Penile Tumours; U28 Peptic Stricture; G9 Peptic Ulcer Disease; FM50 Percutaneous Transluminal Angioplasty and Stents; MI28 Pericardial Disease; C47 Pericardial Effusion; C47 Periodic Health Examination; FM2 Perioral Dermatitis D12 Peripheral Arterial Disease; VS2 Peripheral Nerve Blocks; A22 Peripheral Nerves; NS30 Peripheral Neuropathies; N36 Peripheral Venous Disease; VS7 Peritonsillar Abscess; OT41 Persistent Vegetative State; NS36 Personality Disorders; PS33 Pertussis; P56 Pharmacodynamics; CP7, GM15 Pharmacokinetic Calculation; CP6 Pharmacokinetics; CP3, GM15 Pharmacotherapy; PS42 Pharyngitis; FM49 Phenylketonuria; MG9 Pheochromocytoma; E34 Phobic Disorders; PS16 Photophobia; OP4 Photopsia; OP4 Physical Abuse; P14 Physician Competence; ELOM15 Physiologic Anemia; P41 Physiology of Aging; GM2 Pigmented Lesions; D8 Pilonidal Disease; GS41 Pinguecula; OP13 Pituitary Adenoma; E19, NS14 Pituitary Hormones; E15 Pituitary Pathology; E19 Pityriasis Rosea; D17 Pityriasis (Tinea) Versicolor; D31 Placental blood flow; OB2 Placenta Previa; OB13 Plantar Fasciitis; OR39 Plasmodium spp.; ID38 Platelets; H5, H53 Pleural Abnormalities; MI8 Pleural Effusions; R22 Pneumoconioses; R16 Pneumocystis jiroveci Pneumonia; ID34 Pneumonia; P68, FM49, P80 Pneumothorax; ER22 Poison Prevention; P11 Polycystic Ovarian Syndrome; GY24 Polycythemia Vera; H41 Polyhydramnios; OB20 Polymyalgia Rheumatica; RH27 Polymyositis; RH15 Polypharmacy; GM15 Porphyria Cutanea Tarda; D21 Portal Hypertension; G37 Toronto Notes 2018 R oo Q c P oo Index ok sf ks fre e co m bo o c ee sf e re sf e fre c e Tachyarrhythmias; C18 Talar Fracture; OR38 Tanner Stage; GY5 Tanner Staging; P31 Telogen Effluvium; D38 Temporal Arteritis; OP35, RH20 Temporal Bone Fractures; OT21 Termination of Pregnancy; GY20 Testicular Function; E45 Testicular Tumours; U27 Tests of Thyroid Function; E21 Thalassemia; H18 The Cervix; OB31 The Fetus; OB31 Therapeutic Drug Monitoring; CP9 Thoracolumbar Spine; OR23 Throat; OT3 Thrombocytopenia; H7 Thrombocytosis; H8 Thrombolytic Therapy; MI28 Thrombotic Thrombocytopenic Purpura; H30 Thyroglossal Duct Cysts; OT33 Thyroid; E20, GS60, MI25 Carcinoma; OT37 ok c e re s re sf T ks m co e re sf ok ok oo ok sf e bo bo ok ks ee bo o sf re m eb oo ks fr c eb Salivary Gland Neoplasms; OT30 Salivary Glands; OT30 Sarcoidosis; OP35, R14 Scabies; D27 Scaphoid Fracture; OR21 Scarring Alopecia; D38 Schistosoma spp.; ID41 Schizoaffective Disorder; PS8 Schizophrenia; PS6 Schizophreniform Disorder; PS8 Sclera; OP15 Scleritis; OP15 Scleroderma; NP32 RH13 Sclerosing Adenosis; GS55 Scoliosis; OR44 Scrotal Masses; U29 Seborrheic Dermatitis; D15 Seborrheic Keratosis; D6 Second Trimester Bleeding; GY8 Secondary Angle-Closure Glaucoma; OP27 Secondary Biliary Cirrhosis; G42 Secondary Morphological Lesions; D3 Secondary Open Angle Glaucoma; OP27 Secondary Survey; ER5 Seizure; ER25, N18 Disorders; N18, P76 Sensory Exam; N5 Sepsis; ER38, ID21 R34 Sepsis in the Neonate; P69 Septic Arthritis; ID14, P85, RH5 Joint; OR10 Shock; ID21 Seronegative Rheumatic Disease; RH21 Seropositive Rheumatic Disease; RH6 Sexual Abuse; P15 Assault; ER27 Development; P29 Dysfunction; GY33 Sexuality; GY33 Sexuality and Gender; PS30 Sexually Transmitted Infections; D31, FM42, GY27 Shingles; D29 Shock; ER3, R34 Short Gut Syndrome; GS25 Stomach; G3 Stomas; GS38 Stone Disease; U17 Strabismus; OP36 Strep Pharyngitis; FM49 Stress Fractures; OR41 Stress-Induced Ulceration; G14 Stress Testing; C13 Stroke; ER38, N48 Study Design; PH11 Subacute Thyroiditis; E24 Subarachnoid Hemorrhage; NS18 Subconjunctival Hemorrhage; OP13 Subcutaneous Fungal Infection; ID33 Subdural Hematoma; NS17 Subglottic Stenosis; OT45 Subsequent Prenatal Visits; OB5 Substance-Related and Addictive Disorders; PS21 Sudden Cardiac Arrest; C24 Sudden Infant Death Syndrome; P13 Sudden Sensorineural Hearing Loss; OT20 Suicide; PS4 Patient; ER57 Sunburn; D43 Sunscreens; D43 Supracondylar Fracture; OR17 Surgical Endocrinology; GS60 Sutures; PL6 Syncope; ER26 Syndrome of Inappropriate ADH Secretion; E18 Synovial Fluid Analysis; RH4 Syphilis; D31, GY30, ID25, NP25 Syringomyelia; NS29 Syrinx; NS29 Systemic Infections; ID21, OP32 Systemic Lupus Erythematosus; NP24, P86, RH11 Systemic Sclerosis; RH13 Systemic Toxicity; A23 oo ok sf e Shortness of Breath; ER26 Shoulder; OR10 Shoulder Dystocia; OB38 Shunt Nephritis; NP25 Sialadenitis; OT30 Sialolithiasis; OT30 Sick Euthyroid Syndrome; E27 Sickle Cell Disease; H20 Sideroblastic Anemia; H16 Signs of Airway Obstruction; OT43 Single Gene Disorders; MG7 Sinuses; OT32 Sinusitis; P57, FM49 Skin Anatomy; D2, PL2 Skin Biopsy; PL7 Skin Function; D3 Skin Infections; ID10 Skin Lesions; PL5 Skin Manifestations of Systemic Disease; D40 Skin Masses; PL5 Skin Tags; D6 Skin Ulcer; D5 Skull Base Osteomyelitis; OT16 Sleep Apnea; N47, R32 Sleep-Disordered; FM44, N46, PS29 Breathing; C37 Children; OT41 Disturbances; P12 Sleep-Related Breathing Disorders; R32 Slipped Capital Femoral Epiphysis; OR42 Small Bowel Obstruction; GS21 Small Vessel ANCA-Associated Vasculitis; RH18 Small Vessel Disease; NP29 Small Vessel Non-ANCA Associated Vasculitis; RH18 Smith’s Fracture; OR21 Smoking; N51 Smoking Cessation; FM11 Sodium Homeostasis; NP7 Soft Tissue Infections; ID10, PL15 Solar Keratosis; D33 Solar Lentigo; D9 Solitary Pulmonary Nodule; R30 Somatic Symptom Disorder; PS27 Somatic Therapies; PS49 Sore Throat; FM46 Specific Learning Disorder; P24 Specific Visceral Organ Imaging; MI14 Speech Audiometry; OT11 Spinal Anesthesia; A20 Cord Injury; NS33 Cord Syndromes; NS29 Cord Trauma; ER9 Dysraphism; NS36 Spine; ER9, OR22 Spleen; GS54 Splenectomy; GS54 Splenic Infarct; GS54 Splenic Trauma; GS54 Splenomegaly; H13 Spontaneous Abortions; GY21 Squamous Cell Carcinoma; D34 Stages of Hemostasis; H25 Stages of Puberty; GY5 Stasis Dermatitis; D16 Status Epilepticus; ER25, N19 Steps to Control an Outbreak; PH19 bo S Toronto Notes 2018 T bo eb oo ks fre Retinopathy of Prematurity; OP38 Reversing Agents; A17 Rheumatic Fever; C43 Rheumatoid Arthritis; RH8 Rhinitis; OT23 Rhinosinusitis; OT24 Rickets; E42, MI24 Rings; G9 Rocky Mountain Spotted Fever; ID24 Root Compression; NS25 Rosacea; D12 Rotator Cuff Disease; OR12 Roundworms; ID40 Routine Immunization; P4 Routine Induction; A15 Rule of 9s; PL19 S e R b Index Toronto Notes 2018 Z c W e Warts; D30 Weakness; N9 Webs; G9 Wernicke-Korsakoff Syndrome; N35 West Nile Virus; ID24 White Blood Cells; H5 Wilms’ Tumour; P45, U38 Wilson s Disease; G32 Workplace Legislation; PH23 Wounds; PL8 Infected; PL9 Management; ER17 Wrist; OR20 oo sf re oo ks fre e bo Ulcerative Colitis; G19, G20 Ulce s; PL16 Ulna Shaft Fractures; OR19 Ultrasound; MI3 Umbilical Cord Prolapse; OB38 Umbilical Hernias; GS63 Upper Gastrointestinal Bleeding; G25 Upper GI Bleed; G5 Urea Breath Test; MI27 Urethral Injuries; U33 Urethral Stricture; U8 Urethritis; U16 Urinalysis; NP6 Urinary Incontinence; GY37, U5 Urinary Retention; U6 Urinary Tract Infection; OB28, P57, U12 Urine Biochemistry; NP7 Urine Microscopy; NP6 Urogynecology; GY36 Urological Imaging; MI16 Urological Infections; U12 Urological Neoplasms; U20 Urticaria; D41 Usual Ductal Hyperplasia; GS55 Uterine Abnormal Bleeding; GY6, GY11 Inversion; OB44 Rupture; OB39 Sarcoma; GY39 Uveal Melanoma OP32 Uveal Tract; OP19 Uveitis; OP19 fre ok s U Vesiculobullous Diseases; D19 Vestibular Neuronitis; OT14 Vestibular Schwannoma; NS14 Viral Infections; D29 Virology; ID4 Visual Field Abnormalities; N15 Vitamin B12 Deficiency; H24 Vitamin K Deficiency; H32, P42 Vitiligo; D24 Vitreous; OP21 Vitreous Hemorrhage; OP21 Vitritis; OP21 Vocal Cord Nodules; OT29 Vocal Cord Polyps; OT28 Volvulus; GS36 Vomiting; OB4, P32 von Willebrand Disease; H30 V/Q Scan; MI26 Vulva; GY46 Vulvovaginal Candidiasis; FM50 Vulvovaginitis; GY26 ks fre Y ks fre X ks W oo V b V oo k fre e Vacuum Extraction; OB41 Vagina; GY47 Vaginal Bleeding; ER40 Valve Prosthesis; C43 Valve Repair; C43 Valve Replacement; C43 Valvular Disease; C44 Valvular Heart Disease; C43 Varicose Veins; VS7 Vasa Previa; OB15 Vascular Diseases of the Kidney; NP28 Lesions; D9 Malformations; D10, NS23 Procedures; MI28 Tumours; D10 Vasculitides; P86, RH17 Vasomotor Rhinitis; OT24 Venolymphatic; OT34 Venous Thromboembolism; ER33 H35, OB30 Ventricular Assist Devices; C38 Ventricular Tachyarrhythmias; C22 Verruca Vulgaris; D30 Vertigo; ER39, OT12 Vesicle; D5 co m om bo ok sf re c bo ok sf re e c bo ok sf r bo ok sf r Hormones; E20 Medications; E51 Nodule; OT37 Nodules; E28 Storm; E25 Thyrotoxic Crisis; E25 Thyrotoxicosis; E22 TIA; ER38, OP35 Tibia; OR36 Tic Disorders; N33 Tinea Cruris; FM50 Tinea Pedis; FM50 Tinnitus; OT7, OT15 Toddler’s Diarrhea; P36 Toilet Training; P10 Tonsillectomy; OT42 Tonsillitis; P52 Topical Anesthetics; A23 Topical Ocular Diagnostic Drugs; OP42 Topical Ocular Therapeutic Drugs; OP43 Topical Steroids; D43 Tourette’s Syndrome; N34, NS40 Toxic Adenoma; E25 Toxic Injuries; N17 Toxic Megacolon; GS37 Toxic Multinodular Goitre; E25 Toxicology; ER49 Toxic Shock Syndrome; GY32, ID23 Toxoplasma gondii; ID39 Tracheal Intubation; A8 Tracheoesophageal Fistula; GS64 Transient Synovitis of the Hip; P84 Transmission of Infectious Diseases; ID6 Transurethral Resection of the Prostate; U41 Traumatology; ER7 Assessment; NS31 Injury; ER7 Patient; OR8 Traveller’s Diarrhea; ID13 Travel Medicine; ID42 Travel Precautions; ID42 Treatment Algorithm for Chest Pain; C31 Trematodes; ID41 Tremor; NS39 Trichiasis; OP12 Trichomonas vaginalis; ID37 Trigeminal Neuralgia; N42, NS41 Trimester Bleeding First and Second GY8 Trisomy Chromosomal Syndromes; MG5 Trypanosoma cruzi; ID38 Tuberculosis; ID26 Tubes; MI10 Tubulointerstitial Disease; NP25 Tumour Lysis Syndrome; H52 Ovarian; GY40 Penile; U28 Small Intestine; GS24 Testicular; U27 Twin-Twin Transfusion Syndrome; OB22 U oo T X Xanthelasma; OP13 X-Ray Imaging; MI2 Y oo 10 Index Yeast Infections; D31 Z Zygomatic Fractures; PL32 s fre fe e TORONTO NOTES o oo COMPLETE, CONCISE, AND UP-TO-DATE INFORMATION m co m om m e eb For 34 years, Toronto Notes has been a premier study resource for the Canadian MCCQE and USMLE Step II medical licensing exams This edition provides concise and comprehensive information on the objectives covered by these exams, including the most recent best practice guidelines and up-to-date trials for clinical practice Toronto Notes is an excellent resource for clinical rotations and this text contains 31 subject-specific chapters: fre e om ks re e co m sf ee co m m o sf re Anesthesia and Perioperative Medicine Cardiology and Cardiac Surgery Clinical Pharmacology Dermatology Emergency Medicine Endocrinology Ethical, Legal, and Organizational Medicine Family Medicine Gastroenterology General Surgery and Thoracic Surgery Geriatric Medicine Gynecology Hematology Infectious Diseases Medical Genetics Medical Imaging Nephrology Neurology Neurosurgery Obstetrics Ophthalmology Orthopedics Otolaryngology Pediatrics Plastic Surgery Population Health and Epidemiology Psychiatry Respirology Rheumatology Urology Vascular Surgery 18 ... Interventional Radiology 28 Vascular Procedures Nonvascular Interventions co m MI Medical Imaging MI1 Toronto Notes 20 18 MI2 Medical Imaging Toronto Notes 20 18 c Acronyms fr Acronyms POCUS... om e fre 12 d wk mo mo 2d 1d wk mo mo 10 wk
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