Fundamentals of Clinical Medicine 1

BLOCK1
INTERNAL MEDICINE AND GENERAL SURGERY
Topic 1. Course presentation
Patient assessment - Comprehensive and focused
· Determining the scope of assessment
· Subjective versus objective data
The surgical patients
· Brief history of surgery and recent development. The operating room and current available technologies
Topic 2. Information research, clinical reasoning, assessment, and plan: the process of clinical reasoning. Identifying problems and making diagnosis, generating the problem list
Topic 3. History taking: a comprehensive health history, the techniques of skilled interviewing, the sequence and context of the interviewing, cultural and cognitive contest, exploring patients' perspective
Topic 5. Signs and symptoms. Beginning the physical examination: general survey, vital signs and pain- Overview of general examination
Topic 6 The thorax, lung, and cardiovascular system: techniques of examinations
Topic 7 The abdomen examination related to medical approach (liver, spleen and pancreas problems)
Topic 8 Surgeon's behavior in the Operating room, basic principles of asepsis and patient's preparation to surgery
Topic 9: Physical examination and clinical signs of the abdomen, chest, breast (surgery related), and genito-urinary apparatus part 1
Topic 10. The vascular system: Arterial diseases, Venous and Vascular diagnosis and anamnesis + English/Italian dictionary
Topic 11. Lump, masses, and ulcer
Topic 12. Doctor-patient relationship: clinical cases
Topic 13. Doctor-patient relationship: clinical cases - the physician perspective
Topic 14. PRACTICE LESSON: Case method and problem solving - clinical cases, a multidisciplinary approach
· The foot
· The big belly
· The fainter
Topic 15. PRACTICE LESSON: Clinical tools
· Chest Rx
· ECG
· Blood gases analysis
· Abdominal ultrasonography
· Vascular ultrasonography
Topic 18. PRACTICE LESSON: Video and multimedia material for asyncrous activities

RESPIRATORY DISEASES
Topic 1. Pulmonary function tests and imaging
Understanding the relationship between structure and function, ventilation and mechanics of breathing, principles of plethysmography, bronchial hyper-responsiveness, diffusion, blood flow, ventilation-perfusion relationships, cardio-pulmonary relationships
How to perform and interpret simple spirometry, pletismography and DLCO
How to perform and interpret a 6-minute walking test
How to perform and interpret arterial blood gas analysis
Radiological thoracic anatomy
Radiological features of common pulmonary and pleural diseases
Topic 2. RESPIRATORY DISEASES: Chronic Obstructive Pulmonary Disease - COPD
Definition, classification and etiology of COPD, chronic bronchitis and emphysema and awareness of its heterogeneity
Epidemiology and pathophysiology of COPD, including mechanisms of inflammation, structural changes and cell damage and repair
Risk factors for COPD, including tobacco smoke and anti-protease deficiency (including physiological role of alpha-1-antitrypsin and its genetic characteristics, role of other anti-protease inhibitors, liver disease in antiproteases deficiency)
Possible differential diagnoses /concomitant conditions, including asthma, upper respiratory tract disorders, gastro-esophageal reflux, obliterative bronchiolitis, bronchiectasis.
Relevant investigations including spirometry, other relevant lung function tests, arterial blood gas analysis, peak flow monitoring, bronchodilator and broncho- provocation testing.
General management of COPD including relevant therapeutic measures.
General indication for oxygen supplementation including long-term oxygen therapy, non-invasive and mechanical ventilation, pulmonary rehabilitation and early discharge/hospital at home schemes.
Management of related complications, including pneumothorax, respiratory failure, pulmonary arterial hypertension and cor pulmonale, as well as systemic effects of COPD
Definition and characteristics of COPD exacerbation
Burden of smoking on health from a global perspective (health and economy)
Beneficial effects of smoking cessation in preventing lung and other disease
General overview on treatment modalities for smoking cessation
Topic 3. RESPIRATORY DISEASES: Asthma
Definition, classification (including phenotypes, staging and level of control) and etiology of asthma
Epidemiology and pathophysiology of asthma, including mechanisms of inflammation, structural changes involved, pathology in allergic and non-allergic asthma, asthma severity
Risk factors for asthma, including host and environment factors
Genetics of asthma
Relevant investigations including lung function testing (including bronchodilator and broncho-provocation tests, as well as peak flow monitoring), chest X-ray, CT, nuclear techniques, exhaled NO, skin allergy testing, serum allergy testing and bronchoscopy
Possible differential diagnoses, including early childhood asthma, occupational asthma, vocal cord dysfunction, gastro-esophageal reflux, upper respiratory tract disorders and COPD
Definition and characteristics of asthma exacerbation
Describe the relationship between asthma and rhinitis
Definition, epidemiology, classification, etiology and relevant investigations of non- asthma allergic and eosinophilic lung diseases including hypersensitivity pneumonitis, Churg Strauss Syndrome, acute and chronic eosinophilic pneumonia, allergic bronchopulmonary aspergillosis and drug-induced disease
Topic 4. RESPIRATORY DISEASES, RADIOLOGY: Diffuse parenchymal lung diseases (DPLD)
Definition, classification and etiology of DPLD (Including IPF and sarcoidosis)
Epidemiology and pathophysiology of DPLD
Basic biology and immunology of DPLD
Pulmonary and extrapulmonary manifestations of specific DPLD and OLD
Immunological disorders in respiratory medicine (pulmonary manifestations of collagen-vascular diseases, Hypersensitivity, Pneumonitis, Eosinophilic Pneumonia) Topic 5. RESPIRATORY DISEASES: Respiratory infections, including pneumonia
Definition, classification and etiology of upper respiratory tract infections (URTI), lower respiratory tract infections (LRTI) including pneumonias - community acquired pneumonia (CAP), nosocomial pneumonia (NCP), pneumonia in immunocompromised host
Epidemiology of respiratory infections (microbiology, age related factors, geographical issues, occupational considerations, comorbidities, immunological status)
Relevant investigations: noninvasive (sputum induction, chest X-ray, fluoroscopy, CT, ultrasound), invasive (bronchoscopy, needle aspiration for microbiological sampling)
Related complications such as lung abscess, empyema and sepsis
Criteria for hospitalization and referral to ICU in CAP
Prognosis, predictive factors for high risk of death
Prevention of respiratory infections
Effect of vaccination (e.g. against Influenza and Pneumococcus) on lung disease
Infection control in relation to preventing lung infections
Topic 6. RESPIRATORY DISEASES: Bronchiectasis (Bx) and Cystic Fibrosis (CF)
Definition, classification and etiology of bronchiectasis, acute and chronic bronchitis, bronchiolitis, respiratory tract stenosis and tracheobronchomalacia, tracheo-oesophageal fistula, upper respiratory tract disorders, vocal cord dysfunction, foreign body aspiration, gastro- esophageal reflux
Epidemiology and pathophysiology of bronchiectasis
Knowledge of possible differential diagnoses of Bx
Knowledge of surgical indications and referral for Bx
Management including relevant therapeutic measures and physiotherapy for Bx
Definition, classification and etiology of respiratory and non-respiratory manifestations of CF (including massive haemoptysis, pneumothorax, gastrointestinal disease, diabetes, problems of fertility and pregnancy and psychosocial problems)
Epidemiology and pathophysiology of CF
Relevant investigations (including microbiological investigations)
Related complications such as haemoptysis, pneumothorax, respiratory failure
Chest physiotherapy techniques, nutrition and indications for lung transplantation
Types of lung transplant (single, double and heart-lung), and criteria for patient selection (age, psychological /physical/nutritional status and prognosis)
Topic 7. RESPIRATORY DISEASES: Sleep and Sleep disorders
Definition, classification and etiology of obstructive sleep apnoea syndrome (OSA), central sleep apnoea syndrome (CSA), periodic breathing (PB), obesity hypoventilation syndrome (OHS), periodic limb movement disorder and parasomnias
Epidemiology and pathophysiology of OSA,CSA,PB,OHS
Epidemiology, pathophysiology and etiology of daytime hypersomnolence
Relevant investigations (including screening over-night oximetry and sleep studies (respiratory polygraphy and polysomnography))
Complications of OSA, CSA, PB, and OHS
Methods of treatment (including ventilatory support and CPAP)
Topic 8. RESPIRATORY DISEASES: Pulmonary Vascular Diseases (PVDs)
Definition, classification and etiology of PVDs
Physiology and pathophysiology of the pulmonary circulation
Physiology and pathophysiology of coagulation and thrombosis
Genetic and acquired risk factors for PVDs
Current epidemiology and relevant pathology of PVDs
Respiratory and non-respiratory clinical manifestations and complications
Relevant investigations (lab tests (D-dimer), scintigraphy, CT, MRI, right heart catheterisation)
Topic 9. RESPIRATORY DISEASES, Thoracic Tumours (TT)
Definition, classification and aetiology of TT: lung cancer (LC), mesothelioma (M), metastatic TT (MTT), benign intrathoracic tumours, mediastinasinal (MT), chest wall tumours, sarcoma and lymphoma (L)
Epidemiology and risk factors for TT
Clinical symptoms, syndromes and physical signs of TT including paraneoplastic syndromes
Topic 10. RESPIRATORY DISEASES,: Pleural diseases
Definition, classification and etiology of pleural effusions (serothorax, chylothorax, haemothorax, empyema)
Epidemiology and pathophysiology of infectious, inflammatory, and neoplastic pleural disorders
Macroscopic appearance of pleural fluids
Distinction between transudative and exudative pleural effusions
Definition, classification and etiology of pleural thickening including pleural plaques
Definition, classification and aetiology of pneumothorax (primary and secondary)
Related complications such as tension pneumothorax
Indications for surgical intervention
Topic 12. RESPIRATORY DISEASES: Acute and chronic respiratory failure (RF)
Definition, classification and etiology of acute and chronic respiratory failure (acute respiratory distress syndrome, obstructive lung disease, neuromuscular disease, chest wall diseases, other restrictive diseases)
Epidemiology and pathophysiology of RF
Relevant investigations: non-invasive (chest x-ray, ultrasound, fluoroscopy, CT, nuclear techniques, pulmonary function tests) and invasive (bronchoscopy)
Relevant therapeutic measures such as systemic/inhaled drug therapy, oxygen
therapy, ventilatory support, cardio pulmonary resuscitation, endobronchial therapy, intercostal tube drainage, treatment of sepsis and multi-organ failure)

CARDIOLOGY
Topic 1. Cardiovascular risk
Understand the approaches used to identify the genetic predisposition and environmental factors to cardiovascular diseases
To be able to define monogenic vs. multifactorial cardiovascular diseases: description of examples
Understand the clinical impact of risk stratification
Evaluation of the role as cardiovascular risk factors of race and economical condition
Topic 2 Grading the severity of cardiovascular diseases
Perform a medical interview and a general examination of the cardiac patient
Recognize cardiac sounds and the severity of the cardiovascular disease
Capability to define the severity of heart failure
Topic 3 Resting ECG
Understanding of the cellular and molecular mechanisms involved in the electrical activity of the heart; the anatomy and physiology of the conduction system; and the electrical vectors throughout the cardiac cycle
Understanding the philosophy behind ECG
Understanding the normal ECG and learning to recognize the characteristic appearances of, and the explanation for, the ECG in the main pathological conditions
Topic 4 Arrhythmias
Understanding the epidemiology, pathophysiology, diagnosis and clinical features of arrhythmias and conduction disturbances
Understanding of the classification and definition of bradycardias, tachycardias, supraventricular arrhythmias (including atrial fibrillation and flutter) and ventricular arrhythmias
Describe the use of contrast media
Topic 6 Heart-lung interaction
Discuss of the pathophysiology of lung-heart interactions
Discuss of the clinical and physiological modifications that occur during exercise
Evaluate exercise tolerance and differentiate between cardiovascular and pulmonary aetiology of exercise intolerance
Discuss the difference between cardiac and lung dyspnea
Topic 7 O2 consumption
Discuss of Wasserman plots, CPET parameters and their correlation with prognosis
Discuss the use of VO2 to determine heart failure prognosis
Discuss exercise ventilator efficiency for cardiac, pulmonary and cardiopulmonary diseases
Topic 8 Ischemic heart disease
Understand myocardial ischemia: from pathophysiology to the clinical spectrum (angina, myocardial infarction)
Comprehend the diagnostic tools for assessing myocardial ischemia
Define the basis of the therapeutic approaches
Topic 9 Valvular heart disease
Learning the definition of mitral valve diseases
Learning the definition of aortic valve diseases
Learning the definition of tricuspid valve diseases
Learning the definition of pulmonary valve diseases
Hemodynamics of valvular heart diseases
Topic 10 Pericarditis and endocarditis and cardiomyopathy
Myocarditis and pericarditis: understanding of the mechanisms underlying the disease, the pathophysiology of cardiomyopathy classification the disease and diagnostic and therapeutic approaches
Endocarditis: understanding of the epidemiology, aetiopathogenesis, pathophysiology, diagnosis and therapeutic approaches
Topic 11 Heart failure part 1
Understanding the evolution of concept of Hearth Failure (HF)
Understanding of the epidemiology and prognosis of heart failure with reduced and preserved ejection fraction
Understand the definition of heart failure and recognize the different underlying causes and the precipitating factors of heart failure
Understanding of the pathophysiology of heart failure and systolic and diastolic dysfunction
Topic 12 Heart failure part 2
To be able to evaluate the prognosis of the heart failure patient
To be able to manage acute and chronic HF
Understanding of the role of exercise training programmes in HF patients
Understand the complications of HF
Understanding the therapy approach of HF
Topic 13 Pulmonary hypertension
Understanding of the pathophysiological classification of pulmonary hypertension and the type of investigations used for diagnosing pulmonary hypertension and recognizing the etiology
Understanding of the medical, surgical and interventional management of pulmonary hypertension
Topic 14 Congenital heart diseases
Discuss the anatomy of the heart, veins and great vessels, their major congenital malformations, and the principles of nomenclature
Discuss the physiology of the fetal and transitional circulations; aetiology of congenital heart disease, including the developmental anatomy of the heart and vasculature
Discuss the pathophysiology, natural history and complications of: valve and outflow tract lesions; septal defects; patent ductus arteriosus; Eisenmenger syndrome; coarctation of the aorta; Ebsteins's anomaly; aortic and pulmonary artery malformations; venous anomalies; transposition of the great arteries (complete and congenitally corrected); tetralogy of Fallot; congenital malformations of coronary arteries; cyanotic congenital heart disease and secondary erythrocytosis; and pulmonary hypertension in congenital heart disease.
Evaluate adolescent and adult patients with simple congenital heart defects (grown-up congenital heart disease - GUCH), including those who have undergone cardiac surgery
Describe and recognize physical signs of congenital heart disease and its complications

NEPHROLOGY.
Topic 1 Management of the patient with renal disease
How to identify renal syndromes from the patient's clinical presentation (nephrotic syndrome, nephritic syndrome, positive uranalysis examination, rapidly progressive renal failure, chronic kidney disease) and through specific laboratory investigations, including microscopic urinary sediment analysis.
How to measure kidney function (glomerular filtration rate, tubular and endocrine renal function)
The renal biopsy
Define the impact of preanalytical variables in clinical studies.
Topic 2 The body fluid imbalance and the pathophysiology of the edema
Evaluation of hypovolemia and volume overload in patients with normal and altered renal function
Clinical management and diagnostic algorithm of hyponatremia and hypernatremia
Clinical management and diagnostic algorithm of hypokalemia and hyperkalemia
Clinical management and diagnostic algorithm of acid-base disorders
Topic 3 Glomerular disorders
Clinical presentation and management of most frequent primary and secondary glomerulonephritis, microscopic urinary sediment analysis, follow up of chronic glomerulonephritis
Topic 4 Management of patients with tubulo-interstitial nephritis
Common etiologies, clinical presentation, diagnostic algorithm for both acute nephritis and chronic interstitial nephritis
Topic 5 Approach to patients with urinary tract and renal infection
Common etiologies and clinical presentation of cystitis, acute and chronic pyelonephritis, reflux nephropathy, CAKUT syndrome
Topic 6 Acute kidney injury/acute renal failure
Common etiologies and clinical presentation of acute kidney injury in the hospital and community settings
Differential diagnosis of the various clinical presentations (pre-renal, parenchymal, obstructive renal injury)
Topic 7 Chronic kidney disease - CKD
Common etiologies and clinical presentation of CKD
Systemic consequences of CKD, based on loss of physiologic functions of the kidneys
Endocrine abnormalities linked to CKD. Introduction to the artificial kidney
Topic 8 Introduction to artificial kidney
Topic 9 Renal vascular diseases
Vascular injury to the kidney
Hypertensive vascular disease
Topic 10 Case studies
Four hours of non-formal teaching will be devoted to case studies, where students will be challenged to understand and explain pathophysiological mechanisms of kidney diseases based on a simulated clinical case and on information derived from published articles
Topic 11 Principles of renal transplantation
How to get on the transplant waiting list, selection of the recipients, management of the waiting list, different types of donors, early and late complications of renal transplantation
Topic 12. Management of patients with diabetes
When to suspect a renal involvement and how to detect an early diabetic nephropathy (signs, symptoms and specific laboratory investigations)
The stages of diabetic nephropathy: microalbuminuria, nephrotic syndrome, renal failure and uremia
Treatment and follow-up of diabetic patients
Topic 13 Management of patients with hereditary nephropathies
When to suspect a hereditary nephropathy and how to conduct a clinical interview in such conditions (autosomic dominant polycystic kidney disease, Alport Syndrome, benign familial hematuria, Fabry disease)
Inherited renal tubular disorders : Bartter, Gitelman, RTA etc.)
When to suspect a hereditary nephropathy and how to conduct a clinical interview in such conditions (autosomic dominant polycystic kidney disease, Alport Syndrome, benign familial hematuria, Fabry disease)
Topic 14. Analysis of the urinary sediment
To learn how to recognize diseases based on the characteristics of the urine composition and microscopic analysis

BLOCK1
INTERNAL MEDICINE AND GENERAL SURGERY
Topic 1. Course presentation
Patient assessment - Comprehensive and focused
· Determining the scope of assessment
· Subjective versus objective data
The surgical patients
· Brief history of surgery and recent development. The operating room and current available technologies
Topic 2. Information research, clinical reasoning, assessment, and plan: the process of clinical reasoning. Identifying problems and making diagnosis, generating the problem list
Topic 3. History taking: a comprehensive health history, the techniques of skilled interviewing, the sequence and context of the interviewing, cultural and cognitive contest, exploring patients' perspective
Topic 5. Signs and symptoms. Beginning the physical examination: general survey, vital signs and pain- Overview of general examination
Topic 6 The thorax, lung, and cardiovascular system: techniques of examinations
Topic 7 The abdomen examination related to medical approach (liver, spleen and pancreas problems)
Topic 8 Surgeon's behavior in the Operating room, basic principles of asepsis and patient's preparation to surgery
Topic 9: Physical examination and clinical signs of the abdomen, chest, breast (surgery related), and genito-urinary apparatus part 1
Topic 10. The vascular system: Arterial diseases, Venous and Vascular diagnosis and anamnesis + English/Italian dictionary
Topic 11. Lump, masses, and ulcer
Topic 12. Doctor-patient relationship: clinical cases
Topic 13. Doctor-patient relationship: clinical cases - the physician perspective
Topic 14. PRACTICE LESSON: Case method and problem solving - clinical cases, a multidisciplinary approach
· The foot
· The big belly
· The fainter
Topic 15. PRACTICE LESSON: Clinical tools
· Chest Rx
· ECG
· Blood gases analysis
· Abdominal ultrasonography
· Vascular ultrasonography
Topic 18. PRACTICE LESSON: Video and multimedia material for asyncrous activities