Clinical practice 5th year

A.Y. 2021/2022
18
Max ECTS
216
Overall hours
SSD
BIO/14 MED/05 MED/09 MED/18 MED/19 MED/21 MED/24
Language
English
Learning objectives
The clinical practice course is organized along 3 semesters (1st and 2nd sem 5° year and 1st sem 6° year) and integrates several disciplines to provide the students with conceptual tools to properly manage major clinical presenting problems. The 5° year module integrates Internal medicine and General surgery with Pharmachology, Clinical Pathology, Urology, Plastic surgery,
Starting from a presenting problem (e.g. Jaundice, weight disorders, syncope, chest pain . ) the differential diagnosis and the therapeutic aspects are addressed. By integrating the different discipines students are trained to identify the most appropriate clinical and diagnostic tests to formulate a correct diagnosis and start planning the appropriate treatment. The neurobiological basis of pain and the mechanisms of chronification and palliative care are specificaly addressed. Specific topics relative to Plastic, Thoracic surgery and Urology are addressed.
Expected learning outcomes
At the end of the 5th year module fo the course students are expected to
- Report the basics of clinical judgment in the evaluation of patients starting from their presenting problems
- Manage complex differential diagnoses by the appropriate use of clinical, laboratory, tests and exams findings
- manage the basics of a proper patient's treatment
- know the basics of palliative care and pain management
- know the guidelines and basic principles to correctly address prognostic perspective of patients suffering cancers and
and how to deal with the main complications of chemotherapies
Course syllabus and organization

Single session

More specific information on the delivery modes of training activities for academic year 2021/22 will be provided over the coming months, based on the evolution of the public health situation.
Prerequisites for admission
To attend the Clinical Practice course, students must have already passed all the exams of the first and second year (Fundamentals of Basic Sciences, Cells, Molecules and Genes 1 and 2, Human Body, Functions and Mechanisms of Diseases).
Assessment methods and Criteria
The exam will be organized at the end of the 1st semester of the 6th year, when the course will be completed, and will cover all the topics of Clinical Practice 5th year and Clinical Practice 6th year courses. Students' fulfillment of competencies will be assessed by 2 written tests and an oral session. It is mandatory to pass both the written test to be admitted to the oral examination.
WRITTEN EXAMINATION
1) Written test of General Surgery
A written test using multiple choices Q&A questionnaire. 40 questions, each question has 4 answers, and each answer can be true or false. The questionnaire will be prepared on the slides presented at the frontal lessons (uploaded in the University website for student access) and on the official Textbook. The written test will be considered valid when at least 75% of responses will be answered correctly.
2) Written test of the following disciplines:
Plastic Surgery; Thoracic Surgery; Urology; Clinical Pathology; General psychology; Pharmacology; MED-EF/01
10 questions with 4 answers for each discipline, with only one correct answer. To pass this test students must answer correctly to 6/10 questions in each module.
3) Oral examination of Internal Medicine and General Surgery
ORAL EXAMINATION
For each exam session, the oral examinations of Internal Medicine and General Surgery are scheduled in two separate dates.
An oral discussion with the Course Director and/or Collaborators focused on clinical cases, multi-disciplinary analysis, risk-benefit of various therapeutic alternatives and clinical/research speculations on surgical patients presenting with clinical conditions described in the synchronous and asynchronous learning material as well as in the suggested Textbook. Contents of the asynchronous activities (e.g. Surgery Blog) will be valued, as part of the general assessment of student's participation and acquired knowledge.
The final mark is the weighted average of the two marks obtained in the oral examinations of Internal Medicine and General Surgery.
Written tests and Oral examinations can be taken in different exam sessions. Once passed, the written tests and the oral examinations remain valid.For general information about Exams required skills see also the section "Expected Outcome" below.
BIOSTATISTICS ASSESSMENT
Student assessment is based on the evaluation of a presentation of the work conducted during the practical activities. Students are required to present a draft research protocol for a clinical trial or an observational study. The presentation will be made in the presence of selected components of the exam commission and other students. The presentations will be prepared by small groups of students (maximum 3) and will be divided equally among the group members.
Pharmacology
Course syllabus
TOPIC 1 - The neurobiological bases of pain and the mechanisms of chronification: a matter of neural plasticity
The nociceptive pathway and its modifications during chronification
The descending modulatory pathways as drug targets
TOPIC 2- Focus on opioids
Clinical pharmacology of opioids
Opioids in chronic non-cancer pain: friend or foe?
TOPIC 3 - Pharmacology of nociceptive pain (blended. Asyncronous)
Pathological basis of nociceptive pain
Rational use of drugs for nociceptive pain
TOPIC 4 - Pharmacology of neuropathic pain: the art of combination
Pathological basis of neuropathic pain
Combinatorial therapy for neuropathic pain
TOPIC 5 Cancer pain: not just palliation
The mechanisms of cancer pain and the drugs: beyond the WHO's ladder
Breakthrough cancer pain: the drugs
TOPIC 6 New drugs for pain treatment (blended. Asyncronous)
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
Wall and Melzack's textbook of pain 6th edition 2013 Elsevier Saunders
Essential pain pharmacology. The prescriber's guide H. Smith and M. Pappagallo 2012 Cambridge University pain
Clinical pathology
Course syllabus
TOPIC 1 - Analysis of fluids/biologial samples other than blood: focus on liquor
TOPIC 2 - Analysis of fluids/biological samples other than blood: focus on semen
TOPIC 3 - Analysis of fluids/biological samples other than blood: focus on urine
TOPIC 4 - Analysis of fluids/biological samples other than blood: focus on synovial fluid and pleural fluids
TOPIC 5 - Analysis of fluids/biological samples other than blood: focus on salivary
TOPIC 6 - Analysis of fluids/biological samples other than blood: focus on pericardial and peritoneal fluids
TOPIC 7- Examples of new biomarkers: focus on Irisin and metabolism
TOPIC 8 - Examples of new biomarkers: focus on glycated albumin and glycemic control
TOPIC 9 - Epicardial adipose tissue and cardiovascular risk
TOPIC 10 - New biomarkers of sepsis: focus on presepsin
TOPIC 11 - New biomarkers of cardiac remodeling: focus on ST2/IL33
TOPIC 12 - Cell-free DNA
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
Coleman-Tsongalis, Molecular Pathology, Elsevier 2018
Tietz Fundamentals of Clinical Chemistry and Molecular Diagnostics, 8th Edition
Internal medicine
Course syllabus
TOPIC 1. Less is more
TOPIC 2. Diagnostic tools arterial blood gas measurement
· ECG
· echocardiography
TOPIC 3. Clinical reasoning Diagnosis decision making overview
· Fever of unknown origin FUO
TOPIC 4. Dyspnea: consider differential diagnosis focusing on:
· Pulmonary infections—pneumonia
· Chronic obstructive pulmonary disease
· Heart failure
· Pulmonary hypertension
TOPIC 5. Chest pain: Consider differential diagnosis focusing on:
Cardiovascular causes of chest pain, Precordial chest pain, Coronary hearth disease (Atherosclerotic CAD, ischemic hearth disease)
TOPIC 6. Irregular heart rhythm (Montano, 4h)
· Atrial fibrillation
· Sudden Cardiac Death
TOPIC 7. Transient loss of consciousness (TLOC) (Costantino/Solbiati, 4h)
· Syncope
TOPIC 8. Approach to the adult with anemia: Consider differential diagnosis focusing on:
· Decrease RBC production, Increases destruction of circulating RBC, Blood loss, Systemic disorders
TOPIC 9. Coagulation Disorders:
· Emergency assessment of hemostasis Disorders
· Thrombocytopenia Diagnosis and treatment
· How to use: Old and new anticoagulants
· The management of complex clinical cases
TOPIC 10. Jaundice
· Identify the two main categories of the patients with jaundice (i.e. obstructive and non-obstructive jaundice)
TOPIC 11. Altered hepatic function/edema/ascites
· Identify the main categories of patients with liver disease (Acute and chronic hepatitis, advanced chronic liver disease)
· Consider differential diagnosis focusing on cardiovascular causes of edema (heart failure), renal causes, edema in cirrhosis, hypoalbuminemia
TOPIC 12. Weight disorders - overweight and obesity, Metabolic syndrome and diabetes
· Focus on the metabolic syndrome (increased blood pressure, a high blood sugar level, excess body fat around the waist and abnormal cholesterol level, clinical presentation and management
TOPIC 13. Uncommon abdominal pain: Relationship with rare diseases
TOPIC 14. Immune system disease
· Serological test of autoimmunity
· Pericarditis
· Vasculitis and polymyalgia rheumatic
· Medical condition and pregnancy
TOPIC 15. Geriatric medicine
TOPIC 16. Principles of Human genetics: Clinical cases
TOPIC 17. Value-based Health care
TOPIC 18. Palliative Medicine
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
· Harrison's Principles of Internal Medicine, 20th Edition, McGraw Hill, 2018 (also available as ebook in the digital library of the University of Milano http://www.sba.unimi.it/)
· UP To Date - Evidence Based Clinical Decision Support resource
General surgery
Course syllabus
TOPIC 1 - GENERAL PRINCIPLES OF SURGICAL SCIENCE AND STRUCTURE OF THE COURSE
· Historic perspective: the long road to science
· Ethics, Professionalism and Principles of Surgery
· Pre-operative and Operative Principles
· Operating Room and available technology: staplers, adhesives, probes
TOPIC 2 - ANESTHESIA AND MANAGEMENT OF PAIN
· Principles of Anesthesiology, fluid management, conscious sedation
· Treatment of acute and post-operative pain
· Anatomic pathways of pain, somatic and visceral pain
· Treatment of chronic pain
TOPIC 3 - SHOCK AND PRINCIPLES OF RESUSCITATION
· Bleeding and Transfusion
· Fluids types, Lactate, Acidosis,
· Oxygen delivery and Coagulopathy
· Principles of resuscitation
TOPIC 4 - THE SURGICAL PATIENT- 1
· Metabolism in the surgical patient, nutrition assessment and support
· Coagulation monitoring and management
· Venous Thromboembolism and Pulmonary Embolism
· The concept of safety in surgical procedures
TOPIC 5 - THE SURGICAL PATIENT- 2
· Surgical complications of the wound: wound healing, dehiscence, wound infection
· G.I bleeding, anastomotic leak, and intestinal fistulas
· Surgical infections and antibiotics use
TOPIC 6 - SURGERY FOR FUNCTIONAL DISEASES - ABDOMINAL WALL
· Abdominal wall and Umbilicus
· Inguinal hernia and femoral hernia
· Anterior abdominal wall hernias, repair, prosthetic materials
· Incisional hernias, Parastomal hernias

PROGRAM: SYNCHRONOUS LEARNING 2nd SEMESTER
TOPIC 7 - SURGERY FOR ACUTE INFLAMMATION
· Acute abdomen, Peritonitis, Cholecistitis, Appendicitis
· Management of ascites
· Retroperitoneum: Abscesses, Hematomas, Fibrosis
TOPIC 8 - FROM HUMAN HANDS TO ROBOTS IN SURGERY
· Minimally invasive surgery and simulation training
· Augmented reality and surgical planning
· Image-guided and endoscopic procedures
· Surgery and internet
TOPIC 9 - SURGERY FOR FUNCTIONAL DISEASES - ESOPHAGUS
· Achalasia and Management of Esophageal motility disorders
· Gastroesophageal Reflux Disease
· Diverticular disorders
· Benign and Acquired disorders: perforation, caustics, foreign body
TOPIC 10 - SURGERY FOR FUNCTIONAL DISEASES - ANAL CANAL
· Hemorrhoids
· Anal fissures and fistulas
· Inflammatory and sexually transmitted diseases
· Pelvic floor disorders: incontinence
TOPIC 11 - SURGICAL ONCOLOGY - GENERAL
· General principles: recap of cancer biology and immunology
· Role of surgical and non-pharmacologic treatments in cancer care
· Surgical margins and Lymph-nodal dissection
· Surgery for cure and Surgery for palliation
TOPIC 12 - SURGICAL ONCOLOGY - BREAST
· Diagnosis and planning of surgical treatment
· Mastectomy vs. Breast-preserving approach
· Lymph nodes in breast cancer: sentinel lymph node
· Locally advanced, Inflammatory cancer, Paget, Aged patients
TOPIC 13 - SURGICAL ONCOLOGY - UPPER G.I.- 1
· Diagnosis and workup
· Endoscopic/US diagnosis and principles of endoscopic resections in upper G.I.
· Surgery in early-stage, superficial and locally advanced esophageal cancers
· Cardias: cancer of the gastro-esophageal junction
TOPIC 14 - SURGICAL ONCOLOGY - UPPER G.I.- 2
· Gastric cancers: diagnosis, classification and treatment planning
· Gastrectomies and post-gastrectomy syndromes
· Lymph nodes and gastric cancer
· Gastric Lymphoma, GIST and NET of the stomach
TOPIC 15 - SURGICAL ONCOLOGY - HEPATO-BILIO-PANCREATIC - 1
· Anatomical surgery and surgical anatomy of the liver
· Benign liver lesions: Cysts, Abscesses, Hemangioma, Hyperplasia, Adenoma
· Assessment of liver function, portal hypertension and liver insufficiency
· Primary liver cancer; guidelines for surgical and non-surgical treatment
TOPIC 16 - SURGICAL ONCOLOGY - HEPATO-BILIO-PANCREATIC - 2
· Liver Metastases: role of surgery, assessment of resectability
· Partial liver resections and role of native vs. induced regeneration
· Cancer of the biliary system: curative vs. palliative procedures
· Other primary malignant neoplasms: Hepatoblastoma, Vasculary tumors
TOPIC 17 - SURGICAL ONCOLOGY - HEPATO-BILIO-PANCREATIC - 3
· Exocrine pancreas: acute and chronic pancreatitis
· Cystic Neoplasia of the pancreas, mucinous cysts, IPMN
· Cancer of exocrine pancreas: surgery of tumors of the head, body and tail
· Endoscopic perspective on palliation and pre-operative treatments
TOPIC 18 - SURGICAL ONCOLOGY - LOWER G.I.- 1
· Diagnosis and Dysplasia-Adenoma-Carcinoma sequence in the colon
· Hereditary Cancer Syndromes and Sporadic Colon Cancer
· Colonoscopy, Stomas
· Anatomical surgery and surgical anatomy of the colon
TOPIC 19 - SURGICAL ONCOLOGY - LOWER G.I.- 2
· Diagnosis and treatment planning for Rectal cancer
· Low anterior resection, Abdominal-perineal resection, Sphincter-sparing resection
· Obstructing colo-rectal cancers
TOPIC 20 - SURGERY OF THE SPLEEN; SURGICAL COMPLICATIONS
· Anatomy and functions of the spleen
· Surgical and non-surgical treatments for the spleen
· Emergency operations in immunocompromized, aged, fragile patients
· Acute and late complications of abdominal operations
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
· Sabiston's Textbook of Surgery.- The Biological Basis of Modern Surgical Practice. 20th Edition Elsevier 2017
· Additional material is provided by the slide-presentation used during frontal lessons and seminars, uploaded in the Ariel platform of the University for student access.
Plastic surgery
Course syllabus
Lecture 1 - Burns
Lecture 2 - Wound management
Lecture 3 - Fat grafting
Lecture 4 - Breast reconstruction
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
· Grabb and Smith's Plastic Surgery, Wolters Kluwer
Thoracic surgery
Course syllabus
TOPIC 1 - Lung cancer: epidemiology, aetiology and clinical approach.
TOPIC 2 - Malignant pleural mesothelioma.
TOPIC 3 - Other thoracic malignancies (mediastinum, chest wall and diaphragm).
TOPIC 4 - Regenerative Medicine in Thoracic Surgery.
TOPIC 5 - Interventional pneumology in the diagnosis, staging and treatment of lung cancer.
TOPIC 6 - Personalized medicine in lung cancer: genetic and immunological treatment.
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
· Shields' General Thoracic Surgery by Joseph LoCicero III MD 8th Edition, Wolters Kluwer
· Pearson's Thoracic and Esophageal Surgery Churchill Livingstone last Edition
Urology
Course syllabus
TOPIC 1 - SYNDROMES IN UROLOGY : ACUTE RETENTION OF URINE, HAEMATURIA, OBSTRUCTIVE RENAL FAILURE, INCONTINENCE
TOPIC 2 - UROLITHIASIS
TOPIC 3 - UROTHELIAL & KIDNEY CANCER
TOPIC 4 - TESTICULAR & PROSTATE CANCER
Teaching methods
FOR ALL MODULES: Interactive lectures, Clinical cases, Seminars, Discussion on clinical cases, Case studies
Synchronous learning: video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
GENERAL SURGERY MODULE:
Synchronous learning: Formal lessons delivered by the Course Director, Faculty and Invited Experts will be delivered as formal lectures, seminars, video sessions, video tutorial and clinical case discussions focused on the topics summarized below in the detailed program.
Asynchronous learning: As described in details in the Program below asynchronous learning will be developed through a Surgery Blog (SUB) activated and made accessible to all registered students and professors participating to the course. Each week a real clinical case will be uploaded and opened to groups and individual discussion (Case of the Week). Each Group will be asked to stick to pre-assigned format for case analysis. Contributions to the Surgery Blog will be valued as part of the general assessment of student's participation and acquired knowledge over time.
Teaching Resources
· Smith & Tanagho's GENERAL UROLOGY, Jack W. McAninch & Tom F. Lue, 18th or 19th Edition
Clinical pathology
MED/05 - CLINICAL PATHOLOGY - University credits: 2
Lessons: 24 hours
Professor: Dozio Elena
General surgery
MED/18 - GENERAL SURGERY - University credits: 5
Lessons: 60 hours
Internal medicine
MED/09 - INTERNAL MEDICINE - University credits: 7
Lessons: 84 hours
Pharmacology
BIO/14 - PHARMACOLOGY - University credits: 1
Lessons: 12 hours
Plastic surgery
MED/19 - PLASTIC SURGERY - University credits: 1
Lessons: 12 hours
Thoracic surgery
MED/21 - THORACIC SURGERY - University credits: 1
Lessons: 12 hours
Professor: Petrella Francesco
Urology
MED/24 - UROLOGY - University credits: 1
Lessons: 12 hours