Clinical Medicine 5th Year

Activity "Back to Basics in General Pathology" - Clinical cases discussed by students with the teachers of General pathology (update on oncopathogenesis, oncological immunotherapy, pathogenesis of chronic inflammatory damage) and the teachers of Internal Medicine (aspects of clinical methodology)

Genomics in Medicine
Post-genomics technologies and the perspective of precision medicine/personalized medicine.
The concept of "patient avatar" as an integrated, digitalized model of a patient for personalizing healthcare.
Patient-derived models for cancer precision medicine: tissue organoid- and xenograft-based models.
Bioethics challenges in the era of personalized medicine.

The Molecular Bases of Cancer and the Development of Targeted Treatments
Evolution of targeted therapies in oncology: state of the art and future perspective.
Case studies in the management of the primary, locally advanced and metastatic breast cancer disease for the different triple-negative, luminal, HER2-positive subtypes.
Case studies in the management of the primary, locally advanced and metastatic prostate cancer disease.
Case studies in the management of primary and metastatic colon cancer disease.

Overdiagnosis and Overtreatment in Oncology
The Breast Cancer Paradigm
The Prostate Cancer Paradigm

Cancer Stem Cells and Personalized Medicine in Oncology
The clonal evolution model and the cancer stem cell model.
Cancer stem cells as a diagnostic, prognostic and therapeutic predictive tool in oncology.

Approach to the patient with detection of pulmonary nodule

5th year program:

A
The collection and interpretation of clinical evidence

Collecting evidence from the patient

The anamnestic investigation
1. Collect the patient's medical history, organizing the acquired information for problems and respecting the following criteria:
- Identification of the iatrotropic motif and its history
- Completeness of exploration of the main symptoms and major pathological events
- Search for targeted and relevant information
- Correctness of the terminology used
- Recognition of the patient's agenda in its components of interpretation of symptoms, experience of disease, context and expectations

The physical exam
2. Organize targeted research of clinical signs in relation to the patient's active problems
3. Detect and interpret independently the main pathological signs collected by the patient, Assess the patient's general health status

First level exams
4. Interpret the main first level surveys, with particular attention to the following:
- CBC, reticulocytes, renal and liver function exams, serum electrolytes, glucose, inflammation and necrosis markers, myocardial enzymes, autoantibody serology, serology of autoimmunity and of viral hepatitis, urine test, abdominal ultrasound, echocardiography.
5. Systematically analyze the EKG and recognize its main anomalies regarding: electrical axis, rhythm and conduction disturbances (ventricular and supraventricular ectopic beats, atrial fibrillation, atrial flutter, supraventricular tachycardias, ventricular tachycardias, ventricular fibrillation, right bundle branch block, left bundle branch block, ventricular atrium block), ischemic changes, hypertrophy of the left ventricle.
6. Interpret the blood gas analysis (BGA) and recognize the pictures of respiratory, metabolic, mixed acidosis and alkalosis, and the pictures of alteration of respiratory exchanges.
7. Analyze a chest x-ray regarding:
- systematic exploration of lung parenchyma, pleural planes, heart and mediastinum, costophrenic sinuses and diaphragm, trachea and large bronchi, bone plane;
- recognition of the main pathological pictures (with attention to: pneumothorax, pleural effusion, inflammatory or replacement lung thickening, acute pulmonary edema)
The collection of evidence from the medical literature

8. Identify the knowledge that must be acquired for the correct organization of a clinical problem and translate it into questions that can be answered by the medical literature
9. Set up a search strategy for consulting bibliographic databases
10. Critically evaluate the literature concerning the accuracy of diagnostic methods and the appropriateness of their use, the prognosis of a disease, the effectiveness of an intervention
11. Discuss how the evidence can be applied to the patient in question

B
Diagnostic decisions

Severity assessment
12. Starting from a symptom, a sign or a laboratory alteration, propose strategies aimed at assessing the seriousness of the picture through:
- the stratification (thresholds) of the intensity of the alteration in categories of severity;
- the search for complications or organ damage present (indicators of disease progression) or that the patient could develop in the short, medium and long term;
- the search for comorbidities or even physiological conditions, such as age, which can influence the natural history / prognosis, the success and complications of the treatment of the underlying disease.

Recognize the critical patient and medical emergencies: use blood pressure, heart rate, respiratory rate, glucose, BGA, EKG and clinical picture of the patient to establish the degree of urgency of a diagnostic or therapeutic measure.

Use the main classifications used in the definition of severity of the clinical picture or prognosis (NYHA classification for heart failure; Child classification in liver cirrhosis, etc.).

Discuss the consequences that the definition of severity of the patient can have for diagnostic and therapeutic decisions.

Differential diagnosis
13. Set up appropriate differential diagnosis strategies showing that you are able to:
- establish hierarchies between the diagnostic alternatives on the basis of the attribution of a priori probabilities of disease in relation to the epidemiological knowledge and the critical evaluation of the anamnestic and objective information offered by the clinical case;
- identify the main conditions necessary and sufficient to make a certain diagnosis;
- use the sensitivity and specificity characteristics of the diagnostic investigations, integrating them with the a priori probabilities of the various hypotheses taken into consideration;
- formulate diagnostic strategies based on the use of sensitive investigations for the initial exclusion of hypotheses (less probable but with characteristics of urgency or evolution) and specific investigations for the confirmation of the most probable hypotheses;
- choose the most appropriate diagnostic tests based on the characteristics of accuracy, invasiveness, cost;
- evaluate the effective usefulness of the diagnosis for the patient
14. Due to the particular frequency or clinical relevance they have, the discussion of the following physical, symptomatic or laboratory tests will be privileged for the purpose of evaluating the skills acquired in collecting and integrating the information obtained from the patient (points 1-7) and in setting strategies for differential diagnosis (points 12,13):
Dyspnoea, Digestive bleeding, Chest pain, Anemia, Syncope, Thrombocytopenia, Abdominal pain, Purpura, Vomiting, Lymphadenopathy, Diarrhea, Splenomegaly, Edemas (localized and generalized), Ascites, Fever, Electrolyte and acid-base alterations, Weight loss, Jaundice, Joint and muscle pain

For the purpose of the diagnostic evaluation, the pathologies already faced within the various specialist clinics, the surgical pathologies (see Surgical Clinic exam program) and some pathologies or pathological conditions not always systematically addressed previously, such as:
Venous thromboembolic disease (DVT, PE), SIADH, Sarcoidosis, Rhabdomyolysis, Amyloidosis, Wilson disease, Hypoglycaemia and Hyperglycaemia

C
Therapeutic decisions

The choice together with the patient of a therapeutic intervention
15. Establish and offer the patient therapeutic intervention strategies offered on:
- knowledge of the natural history of the disease, of the possible complications, of the side effects of the treatments in order to define the opportunity and intensity of a therapeutic intervention;
- understanding of the patient's attitudes and motivations for treatment;
- definition of therapeutic objectives (treatment of the disease, prevention of complications, prevention of recurrence, slowing of the progression of the disease and improvement of the structural and functional functioning, alleviation of symptoms and palliation, preservation of the dignity of the patient);
- definition of the efficacy markers (therapy or symptoms, instrumental tests, laboratory tests)
- knowledge of the role of age as a determining factor in adapting the choice and monitoring of therapy to the reality of the patient
Below is a list of pathological conditions for prevalence, severity, evolution, will be likely object of evaluation of in order to explore the maturity acquired by the student in therapeutic decisions:
- Bronchial asthma, acute attack and chronic treatment
- COPD and exacerbation of COPD
- Pneumonia
- Hypertension
- Acute and chronic coronary syndromes
- Atrial fibrillation
- Acute and chronic heart failure
- Venous thromboembolic disease (DVT and PE)
- Diabetes mellitus
- Decompensated liver cirrhosis (ascites, hepatic encephalopathy, prevention of digestive bleeding)
- Infections of the urinary tract
- Acute and chronic renal failure
- Rhabdomyolysis
- Dehydration and hypovolemia
- Electrolyte imbalances (K +, Ca ++)
- Anemia
- Alcoholism
- Osteoporosis
- Non-surgical acute abdomen

Management of the patient with risk factors
16. Recognize risk factors for cardiovascular or neoplastic diseases and use tools for risk quantification.
17. Discuss the effective primary and secondary prevention strategies with the patient taking into consideration the above risk factors.

Approach and management of the cancer patient
18. Recognize and manage the clinical specificities of the cancer patient, in particular as regards the complications expected during the main cancer therapies; the importance, limits and criteria for the correct application of the screening methods
19. Orient the terminal cancer patient and family members between the services for the terminally ill (Hospice, home care, etc.)
20. Illustrate the principles of palliative therapy
21. Propose a therapy for pain control

D
The communication of clinical information to the patient and healthcare personnel
22. Fill in a medical record with attention to the following aspects:
- explanation of the iatrotropic causes, of the active problems, of the severity of the clinical picture, of the main diagnostic hypotheses
- framing of aspects of the disease in the context of the patient's personality and social and family environment for the purposes of diagnostic and therapeutic decisions
- short presentation of the diagnostic and therapeutic objectives
- organization of the clinical diary for problems, indicating useful data for diagnostic and therapeutic decisions, for prognostic evaluation, for monitoring therapy and for communication with the patient and his family.
23. Elaborate a patient discharge report, clearly, completly and summarizing:
- the diagnosis of discharge of the patient
- salient anamnestic data of the patient
- the reason for hospitalization
- the course of hospitalization, organizing it in relation to the main problems (description of the initial presentation framework, diagnostic or therapeutic measures, rational of the decisions taken, evolution) and bringing the patient's condition back to discharge
indications for the period following discharge: drug therapies (clearly reporting the product and the unit dosage of the prescribed pack, the dosage, the times and the methods of intake, the duration), rehabilitation interventions, behavioral advice, control program , alarm criteria for access to the care provider or to health facilities, type of family or individual support from facilities operating in the area.
24. Present a clinical case to offer to the discussion of the Colleagues (presentation of clinical presentation and its interpretation, rationale for the choices and measures adopted and their results, evolution).

Activity "Back to Basics in General Pathology" - Clinical cases discussed by students with the teachers of General pathology (update on oncopathogenesis, oncological immunotherapy, pathogenesis of chronic inflammatory damage) and the teachers of Internal Medicine (aspects of clinical methodology)

Course Syllabus:

Genomics in Medicine
Post-genomics technologies and the perspective of precision medicine/personalized medicine.
The concept of "patient avatar" as an integrated, digitalized model of a patient for personalizing healthcare.
Patient-derived models for cancer precision medicine: tissue organoid- and xenograft-based models.
Bioethics challenges in the era of personalized medicine.

The Molecular Bases of Cancer and the Development of Targeted Treatments
Evolution of targeted therapies in oncology: state of the art and future perspective.
Case studies in the management of the primary, locally advanced and metastatic breast cancer disease for the different triple-negative, luminal, HER2-positive subtypes.
Case studies in the management of the primary, locally advanced and metastatic prostate cancer disease.
Case studies in the management of primary and metastatic colon cancer disease.

Overdiagnosis and Overtreatment in Oncology
The Breast Cancer Paradigm
The Prostate Cancer Paradigm

Cancer Stem Cells and Personalized Medicine in Oncology
The clonal evolution model and the cancer stem cell model.
Cancer stem cells as a diagnostic, prognostic and therapeutic predictive tool in oncology.


6th year program:
The collection and interpretation of clinical evidence
Collecting evidence from the patient
The anamnestic investigation
Collect the patient's medical history, organizing the acquired information for problems and respecting the following criteria:
- Identification of the iatrotropic motif and its history
- Completeness of exploration of the main symptoms and major pathological events
- Search for targeted and relevant information
- Correctness of the terminology used
- Recognition of the patient's agenda in its components of interpretation of symptoms, experience of disease, context and expectations

The physical exam
Organize targeted research of clinical signs in relation to the patient's active problems
Detect and interpret independently the main pathological signs collected by the patient, Assess the patient's general health status

First level exams
Interpret the main first level surveys, with particular attention to the following:
- CBC, reticulocytes, renal and liver function exams, serum electrolytes, glucose, inflammation and necrosis markers, myocardial enzymes, autoantibody serology, serology of autoimmunity and of viral hepatitis, urine test, abdominal ultrasound, echocardiography.
Systematically analyze the EKG and recognize its main anomalies regarding: electrical axis, rhythm and conduction disturbances (ventricular and supraventricular ectopic beats, atrial fibrillation, atrial flutter, supraventricular tachycardias, ventricular tachycardias, ventricular fibrillation, right bundle branch block, left bundle branch block, ventricular atrium block), ischemic changes, hypertrophy of the left ventricle.
Interpret the blood gas analysis (BGA) and recognize the pictures of respiratory, metabolic, mixed acidosis and alkalosis, and the pictures of alteration of respiratory exchanges.
Analyze a chest x-ray regarding:
- systematic exploration of lung parenchyma, pleural planes, heart and mediastinum, costophrenic sinuses and diaphragm, trachea and large bronchi, bone plane;
- recognition of the main pathological pictures (with attention to: pneumothorax, pleural effusion, inflammatory or replacement lung thickening, acute pulmonary edema)
The collection of evidence from the medical literature

Identify the knowledge that must be acquired for the correct organization of a clinical problem and translate it into questions that can be answered by the medical literature
Set up a search strategy for consulting bibliographic databases
Critically evaluate the literature concerning the accuracy of diagnostic methods and the appropriateness of their use, the prognosis of a disease, the effectiveness of an intervention
Discuss how the evidence can be applied to the patient in question

Diagnostic decisions

Severity assessment
Starting from a symptom, a sign or a laboratory alteration, propose strategies aimed at assessing the seriousness of the picture through:
- the stratification (thresholds) of the intensity of the alteration in categories of severity;
- the search for complications or organ damage present (indicators of disease progression) or that the patient could develop in the short, medium and long term;
- the search for comorbidities or even physiological conditions, such as age, which can influence the natural history / prognosis, the success and complications of the treatment of the underlying disease.

Recognize the critical patient and medical emergencies: use blood pressure, heart rate, respiratory rate, glucose, BGA, EKG and clinical picture of the patient to establish the degree of urgency of a diagnostic or therapeutic measure.

Use the main classifications used in the definition of severity of the clinical picture or prognosis (NYHA classification for heart failure; Child classification in liver cirrhosis, etc.).

Discuss the consequences that the definition of severity of the patient can have for diagnostic and therapeutic decisions.

Differential diagnosis
Set up appropriate differential diagnosis strategies showing that you are able to:
- establish hierarchies between the diagnostic alternatives on the basis of the attribution of a priori probabilities of disease in relation to the epidemiological knowledge and the critical evaluation of the anamnestic and objective information offered by the clinical case;
- identify the main conditions necessary and sufficient to make a certain diagnosis;
- use the sensitivity and specificity characteristics of the diagnostic investigations, integrating them with the a priori probabilities of the various hypotheses taken into consideration;
- formulate diagnostic strategies based on the use of sensitive investigations for the initial exclusion of hypotheses (less probable but with characteristics of urgency or evolution) and specific investigations for the confirmation of the most probable hypotheses;
- choose the most appropriate diagnostic tests based on the characteristics of accuracy, invasiveness, cost;
- evaluate the effective usefulness of the diagnosis for the patient
Due to the particular frequency or clinical relevance they have, the discussion of the following physical, symptomatic or laboratory tests will be privileged for the purpose of evaluating the skills acquired in collecting and integrating the information obtained from the patient (points 1-7) and in setting strategies for differential diagnosis (points 12,13):
Dyspnoea, Digestive bleeding, Chest pain, Anemia, Syncope, Thrombocytopenia, Abdominal pain, Purpura, Vomiting, Lymphadenopathy, Diarrhea, Splenomegaly, Edemas (localized and generalized), Ascites, Fever, Electrolyte and acid-base alterations, Weight loss, Jaundice, Joint and muscle pain

For the purpose of the diagnostic evaluation, the pathologies already faced within the various specialist clinics, the surgical pathologies (see Surgical Clinic exam program) and some pathologies or pathological conditions not always systematically addressed previously, such as:
Venous thromboembolic disease (DVT, PE), SIADH, Sarcoidosis, Rhabdomyolysis, Amyloidosis, Wilson disease, Hypoglycaemia and Hyperglycaemia

Therapeutic decisions

The choice together with the patient of a therapeutic intervention
Establish and offer the patient therapeutic intervention strategies offered on:
- knowledge of the natural history of the disease, of the possible complications, of the side effects of the treatments in order to define the opportunity and intensity of a therapeutic intervention;
- understanding of the patient's attitudes and motivations for treatment;
- definition of therapeutic objectives (treatment of the disease, prevention of complications, prevention of recurrence, slowing of the progression of the disease and improvement of the structural and functional functioning, alleviation of symptoms and palliation, preservation of the dignity of the patient);
- definition of the efficacy markers (therapy or symptoms, instrumental tests, laboratory tests)
- knowledge of the role of age as a determining factor in adapting the choice and monitoring of therapy to the reality of the patient
Below is a list of pathological conditions for prevalence, severity, evolution, will be likely object of evaluation of in order to explore the maturity acquired by the student in therapeutic decisions:
- Bronchial asthma, acute attack and chronic treatment
- COPD and exacerbation of COPD
- Pneumonia
- Hypertension
- Acute and chronic coronary syndromes
- Atrial fibrillation
- Acute and chronic heart failure
- Venous thromboembolic disease (DVT and PE)
- Diabetes mellitus
- Decompensated liver cirrhosis (ascites, hepatic encephalopathy, prevention of digestive bleeding)
- Infections of the urinary tract
- Acute and chronic renal failure
- Rhabdomyolysis
- Dehydration and hypovolemia
- Electrolyte imbalances (K +, Ca ++)
- Anemia
- Alcoholism
- Osteoporosis
- Non-surgical acute abdomen

Management of the patient with risk factors
Recognize risk factors for cardiovascular or neoplastic diseases and use tools for risk quantification.
Discuss the effective primary and secondary prevention strategies with the patient taking into consideration the above risk factors.

Approach and management of the cancer patient
Recognize and manage the clinical specificities of the cancer patient, in particular as regards the complications expected during the main cancer therapies; the importance, limits and criteria for the correct application of the screening methods
Orient the terminal cancer patient and family members between the services for the terminally ill (Hospice, home care, etc.)
Illustrate the principles of palliative therapy
Propose a therapy for pain control

The communication of clinical information to the patient and healthcare personnel
Fill in a medical record with attention to the following aspects:
- explanation of the iatrotropic causes, of the active problems, of the severity of the clinical picture, of the main diagnostic hypotheses
- framing of aspects of the disease in the context of the patient's personality and social and family environment for the purposes of diagnostic and therapeutic decisions
- short presentation of the diagnostic and therapeutic objectives
- organization of the clinical diary for problems, indicating useful data for diagnostic and therapeutic decisions, for prognostic evaluation, for monitoring therapy and for communication with the patient and his family.
Elaborate a patient discharge report, clearly, completly and summarizing:
- the diagnosis of discharge of the patient
- salient anamnestic data of the patient
- the reason for hospitalization
- the course of hospitalization, organizing it in relation to the main problems (description of the initial presentation framework, diagnostic or therapeutic measures, rational of the decisions taken, evolution) and bringing the patient's condition back to discharge
indications for the period following discharge: drug therapies (clearly reporting the product and the unit dosage of the prescribed pack, the dosage, the times and the methods of intake, the duration), rehabilitation interventions, behavioral advice, control program , alarm criteria for access to the care provider or to health facilities, type of family or individual support from facilities operating in the area.
Present a clinical case to offer to the discussion of the Colleagues (presentation of clinical presentation and its interpretation, rationale for the choices and measures adopted and their results, evolution).

Approach to the patient with hemophtoe
Patient management with TB
When the disease is contagious: criteria and methods of isolation
How to set up antibiotic therapy
Urinary tract infections
Fungal infections

Professionalising tutorial activities "Clinical reasoning: Making Thinking Visible (MTV)" - Strategies for the critical collection of clinical evidence and their interpretation
Assessment of disease severity in terms of severity thresholds or alteration intensity
Formulation of rational pathways of diagnosis and therapy;
Definition of the risk-benefit ratio using threshold approach models to clinical decisions
Management of clinical problems with ethical implications

Clinical discussion on collection of the patient's personal history, communication processes and relational skills of shared decision making