Ateneo - UPO

The most commonly encountered diseases and conditions in Internal Medicine are presented with a case-based approach. The most relevant aspects of each case (including essentials of epidemiology, pathophysiology, differential diagnosis, treatment and prognosis) are discussed interactively.

Harrison's Principles of Internal Medicine, 21/E
McGraw-Hill Education (2022).
The Washington Manual of Medical Therapeutics, 37/E. Lippincott, Williams & Wilkins (2022)

The course is aimed at the training of a prospect physician who, taking into account the (necessarily limited) experience gained at this stage of his/her career, is able to take care of the most common human health problems, understanding the patient in its complexity, from a multidisciplinary, interprofessional and integrated point of view. The reference discipline is Internal Medicine, that is, the one that deals with the non-surgical diagnosis and therapy of all "internal" organs and systems, hence the most "generalist" of the medical specialties. At the end of the course the student must have:
• Gained knowledge useful for clinical practice regarding the most common internal medicine problems, such as, for example, heart failure or acute exacerbation of chronic obstructive bronchopneumopathy; the achievement of this goal can be measured through the performance in the ad hoc multiple choice quiz.
• Developed, for the same purpose, clinical abilities (eg, proper and thorough history taking and physical examination, setting up of laboratory and instrumental investigations) aimed at solving problems in the single proposed case study (with regard to diagnosis, clinical monitoring, therapy and involvement of the patient and the family in the care process); the achievement of this objective is measurable through the performance in the solution of a structured case study proposed ad hoc;
• Learned to recognize and fill their limits through smart use of references, such as tutors themselves, manuals and textbooks, electronic resources (eg, UpToDate®);
• Understood systems in which the practice of medicine occurss, eg. the relationship between hospital medicine and medicine in the community.
The achievement of these last two objectives is measured during clinical clerkship.

To achieve course objectives in full, the student should have gained sufficient knowledge of biological bases of the diseases, physiopathology, as well as clinical presentation and diagnostic workup of the most common cardiovascular, respiratory, infectious, gastrointestinal, renal, endocrine, hematological, skeletal muscle. Translated in terms of pre-teaching, the ideal student for the course of Internal Medicine (Clinica Medica e Terapia Medica) is the one who has fully achieved the objectives described in the courses of Systematic Pathology, Integrated Surgical Pathology, Integrated Medical Pathology I, Integrated Medical Pathology II and Special Pharmacology.

The course consists of:
• 60-minutes frontal lessons, all introduced from an exemplary clinical case by which to analyze the approach to diagnosis, therapy and prognosis of the most common internal medicine conditions observed in clinical practice;
• N. = 100 hours of clerkship, of which N. = 80 spent in the Internal Medicine ward and clinic and N. = 20 in the office of a general practitioner. SBAR skills, problem-solving, patient's approach (physical examination skills) and bedside procedures are taught; the active participation of the student the development of a critical spirit and the progressive ability to manage problems independently are strongly stimulated.
• Extensive use of the DIR platform, through which the student accesses podcasts of the frontal lessons provided in the classroom during this academic year and in previous courses, further study materials (eg, international guidelines, video tutorials, etc. .) and self-assessment and learning quizzes, with correct answer commented.

Large use of resources for blended learnng (webcasts, quizzes)

(Knowledge)
Multiple choice quiz consisting of N. = 90 questions with N. = 5 possible answers, of which only one correct, extracted from a pool of N. = 720 different questions pertaining to the modules of Internal Medicine and Therapeutics. N = 30 questions (33%) have already been presented and resolved during frontal lessons, podcasts and self-learning quizzes; the remaining questions will be new but always relevant to the content of the course. The minimum threshold for passing the test is 60/90 (66%) of correct answers. A level of excellence is achieved with a correct answer to 81/90 (90%) or more of the questions.
(Competence)
Simulated clinical case, structured to deal with a case that actually took place in contemporary clinical practice, whose specifications are progressively revealed, through questions (multiple choice with single response, multiple choice with multiple possible answers, true or false, associations) aimed at to enhance the student's ability to solve physical and instrumental semeiotics problems, diagnostic workup, treatment and follow-up. The case used is always representative of a major medical problem commonly encountered in medical practice with an impact on quantity and quality of life; the pathology of reference for the case is on a list posted on the DIR. The threshold for passing the test is to give a correct answer to 60% of the proposed queries.
(Cross Competencies)
Evaluated with immediate feedback during the clerkship in Internal Medicine, at structured times such as handoffs, pre-ward round briefing, ward round/clinic activities with the tutor(s).

1. General Aspects of Internal Medicine. Problem solving and clinical decision-making. Approach to the patient with venous thromboembolism. Value of EGA, ECG, Chest X-ray and D-Dimer. Diagnostic algorithms (Wells score), indications for positioning of caval filters and thrombolysis. Health Maintenance in men and women; gender-specific guidelines.
2. Geriatric problems. General elderly care. Assessment of basic and instrumental activities of daily living. Dementia: Diagnosis and Care of the demented patient. Comorbidity and geriatric syndromes. Fragility: diagnosis, prevention and care. The hospitalized elderly patient. Delirium: diagnosis, prognosis, treatment. Falls: risk factors, objectivity, prevention. Deprescribing. ACE Units and Models of Care for the 21st Century.
3. Cardiovascular problems. Bradyarrhythmia and AV blockade as a cause of syncope, ECG signs in ischemic heart disease and other conditions (hypercalcaemia, hypocalcemia, brain lesions, COPD). Approach to the patient with atrial fibrillation. a) clinical manifestations, indications for cardioversion in urgency; b) choice of therapeutic strategy; c) oral anticoagulant therapy. Score, anti-VITK vs. DOACs. Approach to the patient with angina pectoris: clinical diagnosis, stress testing, medical therapy. Gender differences in cardiology. Approach to the patient with a heart murmur: use of the physical semeiotics. Hypertrophic cardiomyopathy and sudden cardiac death of the young. Aortic valve stenosis: diagnosis, prognosis, indications for surgical treatment. Approach to the patient with heart failure: clinical manifestations, diagnostic iteration. Treatment Algorithm with Acute Presentation; considerations on the treatment of acute discomfort. Approach to the patient with hypertension: classification, correct measurement of blood pressure in the various settings. Estimating global cardiovascular risk and lifestyle measures to reduce it. Conditions requiring immediate treatment (eg, pheochromocytoma). Pharmacological therapy choices based on individual cardiovascular risk and pressure levels. Therapy in the diabetic and in the elderly subject. The patient with pericarditis with / without cardiac tamponade. The patient with pulmonary hypertension.
4. Respiratory problems. Clinical interpretation of TFR. Methods of oxygenation. Approach to the patient with pleural effusion. Characteristics of pleural fluid and related investigations: Light criteria and differential diagnosis of exudates and transudates. Tuberculous pleuritis. Eosinophilic pleuritis. Indications for placement of a pleural drainage. Approach to the patient with acute exacerbation of COPD: causes, diagnosis, severity assessment, hospital therapy. Indications for non-invasive ventilation. Prevention: vaccinations, proper use of inhaled therapy and support for smoking cessation. Approach to the patient with a solitary pulmonary nodule. Approach to community-acquired pneumonia: etiology, risk stratification, initial investigations, therapy in different care settings, criteria for discharge.
5. Infectious problems. Antibiotic stewardship. Treatment of complicated and uncomplicated urinary tract infections. Emerging infections in the hospital setting .: Acynetobacter baumannii and enterobacteriaceae resistant to carbapenem, prevention and treatment. Approach to the patient with S. aureus infection in the various districts. Anti-staphylococcal drugs commonly used. Approach to HIV-positive patients: diagnosis of HIV infection with Italian legislation specifics. Acute retroviral syndrome. Common presentations in H .: PCP and Cryptococcus meningitis. History, physical examination, initial management of the HIV +ve patient by generalists. Logic of anti-retroviral therapy, major adverse effects, IRIS. Monitoring over time; vaccinations and chemoprophylaxis.
6. Gastrointestinal problems. Approach to the patient with acute diarrhea. When, how and why to investigate acute diarrhea. The traveler's diarrhea and C.difficile colitis. Symptomatic and etiologic therapy. Approach to a patient with chronic diarrhea. Diarrhea from intolerance to carbohydrates, NE tumors, bile salts, celiac disease, IBD, microscopic colitis, and irritable bowel syndrome. Symptomatic and causal therapy. Approach to the patient with impaired liver function tests. Patterns of cytonecrosis and cholestasis and related investigations. Approach to the patient with chronic viral hepatitis; results and limitations of current treatment options. Approach to the cirrhotic patient with hydrosaline retention: diagnosis and treatment. Spontaneous bacterial peritonitis. Hepatic-renal syndrome. Approach to the patient with liver encephalopathy: types, severity, clinical expression, precipitating factors. Rational treatment and recurrence prevention; prognostic aspects. Periodic monitoring in cirrhotic: esophageal varices, nutritional status, hepatocellular carcinoma.
7. Renal Problems. Approach to the patient with electrolyte and/or acid-base disorders. Clinical manifestations of acute and chronic hyponatremia, differential diagnosis depending on volume status. Syndrome of inappropriate antidiuresis: diagnostic criteria and associated conditions. Treatment of hyponatremia. Hypernatremia: risk factors in the elderly and diagnosis. Diabetes insipidus in its various expressions. Rational treatment: water deficit estimate, volume and infusion rate calculations, treatment risks. Hypokalemia caused by diuretics vs. Less common causes: hypertension, ECF / ICF redistribution, reduced GI intake or GI absorption, acid-base balance alteration. Metabolic Alkalosis: initiating factors and maintaining factors. Measurement of urinary chlorides as key for the differential diagnosis. Hyperkaleemia: Causes, Symptoms, Differential Diagnosis and Therapy. Approach to the patient with acute renal damage. Differential diagnosis (prerenal, renal). Contrast-induced nephropathy: diagnosis and prevention.
8. Endocrine Problems. Management of hyperglycemia and diabetes in the hospital. Prognostic Impact, Therapy and Glycemic Targets Depending on the Setting. Calculation of insulin dose, route of administration. "Handoff" of the patient with diabetes / hyperglycemia from the hospital department to the territory. Total or relative insulin deficiency states: DKA and HHS, directions for early treatment and monitoring. Hypoglycemia in diabetic (major causes) and non-diabetic. Approach to the patient with Hyper / Hypocalcaemia.
9. Blood Problems. Approach to the anemic patient. Interpretation of erythrocyte indices. Diagnosis of iron deficiency anemia vs. anemia of inflammation. Iron in the diet, oral supplements, parenteral therapy. Macrocytosis and megaloblastic anemia. Causes of vitamin B12 deficiency and folate deficiency; clinical manifestations, differential diagnosis and therapy. Diagnostic workup, with particular reference to hemolytic anemia and multiple myeloma. Approach to the patient with thrombocytopenia. Classification according to the pathophysiological mechanism and the care setting. Use of peripheral blood smear examination in differential diagnosis. Thrombocytopenia Thyroid and Immune Thrombocytopenia (DIC, TTP / HUS). Approach to the patient with hypereosinophilia.
10. Musculo-skeletal problems. Approach to the patient with arthritis. Diagnostic workup: identification of the problem on the locomotor apparatus, anatomical definition, distribution, inflammatory / non-inflammatory pattern, acute / chronic course. Related conditions. Acute Monoarthritis: the patient with crystal arthritis. Approach to the patient with vasculitis: clinical manifestations, clues, diagnostic investigations. Nomenclature according to the Chapel Hill Consensus Conference: diagnosis and treatment of vasculitis of small, medium and large vessels.

(Knowledge)
- Epidemiology, Clinical manifestations, Differential Diagnosis, Therapy, Follow-up and Prognosis of the Most Common Clinical topics in Internal Medicine
(Competence)
- Applying the principles of clinical reasoning to a specific clinical case by choosing the most common diagnostic procedures, analyzing and interpreting the results effectively and efficiently;
- Choice of therapies in the individual patient, taking into account differences with regard to age, gender, hepatic and / or renal function, recognizing the degree of urgency with which such therapies should be administered and the possibilities of cost containment;
- Ability to undertake adequate preventative and protective actions in relation to the disease, while maintaining and promoting the health of the individual, the family, and the community.
(Cross Competencies)
- knowing how to present a patient's problems in an orderly and structured way;
- be able to read, understand and comment on technical material from treats or manuals and point-of-care sources.
To achieve an advanced level, the student must demonstrate:
- be able to choose rational solutions for complex problems, using the didactic resources made available, eg. UpToDate®
- to give the importance of cost containment, eg in the context of the Choosing wisely program;
- Identify the need for patient monitoring and patient/family involvement in processes such as diagnostic workup and treatment.