KONSTANTINOS P. MAKARITSIS, Professor 

Clinical Exercise

G. Dalekos   – A. Kapsoritakis – E. Rigopoulou – K. Makaritsis – K. Zachou – G. Ntaios – N. Gatselis – A. Bargiota – G. Efremidis, Ch. Katsiari   – Th. Eleftheriadis – D. Bogdanos – N. Giannakoulas  – A. Manolakis – A. Kotsakis – E. Saloustros – F. Koinis –S I. Pantazopoulos

 Course Lectures

G. Dalekos  – E. Rigopoulou – K. Makaritsis – A. Kapsoritakis – Z. Daniil – K. Gourgoulianis – K. Zachou – G. Ntaios – N. Gatselis   – D. Bogdanos – A. Manolakis – I. Pantazopoulos

The student must have attended and been successfully examined in at least three (3) of the following courses

1. General Morphology ii. Integrative Systems Physiology iii. Neurophysiology and Endocrine Physiology iv. Medical Microbiology I v. Immunology vi. Basic and Clinical Pharmacology: Introduction – Nervous System vii. Medical Liability and Ethics viii. Pathological Physiology I ix. Clinical Examination and Diagnosis in Internal Medicine

Face to face

Microsoft Power Point software is used to deliver the lectures.

The Library has the necessary textbooks for the course. Students also have access to the international scientific databases (PubMed) available at the Library.

All coursework is delivered using a computer project using Power Point. The above course lectures are posted on the Medical School and University Internal Medicine Clinic websites with free access by Medical School students. CD-DVDs are also used to teach the Clinical Tutorial. Finally, the course instructor and other teachers’ emails can be used for communication between students and teachers, and students are encouraged to use this method of communication as well. Also information or announcements regarding the course are posted on the Medical School and University Internal Medicine Clinic websites with free access by Medical School students.

– Student’s performance evaluation is done by oral questions on patients’ problems during clinical exercises and by written tests at the end of the semester. Students are evaluated by the clinical exercise tutors at the end of the semester in their ability to provide the basic differential diagnosis of pathological diseases based on the main symptoms and signs of the patient. The grading can be inadequate, moderate, good and very good. The course is also tested during the exams periods according to the written examination system. Exams are particularly demanding and it is usually necessary to answer at least 70% of the questions correctly so that the student can reach a passing grade. Written questions may include Multiple choice questions or short-answer question. It can be seen from the above that the workload for the students for the Internal Medicine I course is extremely heavy and the requirements are particularly high. Based on the above the course of Internal Medicine I has been rated by nine (9) credits (ECTS). The evaluation criteria are accessible by students on the course website : http://83.212.32.147/internalmedicine/index.php/el/pathology-i .

Finally, a special questionnaire is available to the students at the end of the semester, so that the students can evaluate each one of the tutors for each of the 2-hour lectures (2 times / week) and for each of the 2 hour clinical tutorials (2 times / week). Students are also encouraged to express their views on the overall educational process of the course and any proposed changes.

The results of the above questionnaire responses are appropriately utilized aiming on improving the educational process for the course.

The Internal Medicine I course is one of the core courses of the Medical School and implements important requirements from the students. Students are required to dedicate many hours in studying and understanding various diseases. It is also required to attend 4 hours per week of lectures as well as 4 hours per week of clinical practice in the wards of the University Internal Medicine Clinic, where a large number of patients are hospitalized suffering from various diseases and requiring appropriate treatment. The goal of teaching is to gain knowledge and experience in the main entities of Internal Medicine.

Goal

Internal Medicine I is taught in the 6th semester as part of the Internal Medicine course and is accompanied by Internal Medicine II which is offered in the 7th semester. The teaching of Internal Medicine I aims to get knowledge and gain experience in the Internal Medicine entities, e.g. Infections – Cardiovascular Diseases – Respiratory Diseases – Gastrointestinal Diseases – Liver Diseases – Biliary Diseases – Pancreatic Diseases.

Objectives 

The objectives of the course can be specified as follows:

• Acquire systematic knowledge of the main disease entities (diseases and clinical syndromes). The student must become familiar with the definitions, epidemiology, pathogenesis, natural history, modes of invasion, symptoms, signs, laboratory and imaging findings, diagnosis, complications, prognosis, and treatment of individual diseases of Internal Medicine.
• Gain of experience by the patient’s bed regarding the symptoms, signs, laboratory and imaging findings of specific diseases.
• Critical evaluation of the above mentioned findings for each patient and their implementation in the application of diagnosis and treatment.

Requirements 

• In order for the medical student to attend the Internal Medicine I course efficiently, he/she must have knowledge of all courses of the previous five semesters. This applies irrespective of the requirements of the Study Guide of the Medical School that determine the prerequisite courses. However, the admission of the students to the course is made according to the regulations originating from the Study Guide of the Medical School. The knowledge of the previous courses corresponds to the normal educational procedure and leads to the maximum benefit of the student attending the Internal Medicine I course.
• A significant part of the acquired knowledge in the first five semester courses is closely related to the description of the diseases and conditions of the Internal Medicine I course. This knowledge is part of the Internal Medicine curriculum required for the successful completion of the Internal Medicine I course and is clearly described below.

Structure of the knowledge the student has to acquire in the Internal Medicine I course 

• The knowledge that the student has to acquire in the Internal Medicine I course as described below is not adapted to a specific Internal Medicine textbook and the students can use various books of their choice. There are also reviews in each chapter of Internal Medicine prepared by the teaching professors of the Medical School, which can be used as an additional important aid for the student.
• The required knowledge is structured in four categories: very important, important, desirable and minimum. The stratification was done according to the following criteria: (1) the frequency of diseases in the Greek population, (2) their importance in understanding the broader fields of Internal Medicine, (3) their utility as a tool irrespective of the specialty to be pursued by the student in the future and (4) overlap with other undergraduate clinical courses.
• This stratification was done to assist the students in their study and it should not be misinterpreted that only very important knowledge is sufficient for success. In fact, the important ones are no different from the very important ones or the other 2 categories and should be used only as an assistance studying guide by the student. The concept of desirable or minimum knowledge should not be taken as an optional acquisition of that knowledge, but as a focus on the most essential elements of the relevant chapters.

Skills – gaining experience 

• Experience response is achieved by tutoring students in small groups under the guidance of a teacher. Teams are made to have the smallest possible number of students and in any case not to exceed nine (9). The clinical exercise takes place in patients’ wards at the Internal Medicine Clinic in the University Hospital of Larissa. The patients have been pre-selected by the instructor and effort is made to include patients with a broad spectrum of diseases.
• In this clinical exercise the student comes into direct contact with real facts and gains experience in the following:

– Expands and improves its ability to take the medical history, identify important data and evaluate them.

– Improves his ability in physical examination and gives him the opportunity to familiarize himself with a variety of physical findings as well as their evaluation.

– Learns to identify and organize patient problems as they arise from the history and physical examination and to enrich them based on the basic hematological, biochemical and radiological tests.

– Learns the process of differential diagnosis. This includes the possible diagnoses based on history, physical examination and basic tests, along with a diagnostic plan based on the necessary microbiological, hematological, biochemical, imaging and clinical tests. He also learns to evaluate the contribution of each test in the establishment of diagnosis.

– Acquires experience in the management and treatment of each patient according to the final diagnosis.

• The clinical practice steps followed by the students in order to reach a diagnosis are described below and are adjusted according to the special findings for each patient.

– Students (usually 2 to 6) take a complete history of the patient and perform a complete physical examination. With the help of the instructor a critical evaluation of the history data as well as the findings of the physical examination is made. Thus students gain immediate experience of the main symptoms as described by the patient and evaluate them with regard to their onset, duration, intensity, quality and other characteristics. They also gain experience in physical examination, according to the course named Clinical Examination, which is offered in the 5^th semester and includes the learning and evaluation of a complete physical examination.

– Based on the history, the findings of the clinical examination and the assistance of the instructor, the students list the patient’s major problems and the main diagnostic possibilities.

– Then the findings of basic laboratory tests (complete blood count, ESR, urine tests, biochemical routine tests) are obtained and in conjunction with the findings from the history and physical examination might narrow the number of the possible diagnoses.

– The more advanced microbiological, hematological, biochemical, imaging and clinical tests required to investigate the patient are then discussed on the basis of diagnostic possibilities.

– If the results of such advanced investigation are available, they are evaluated with the assistance of the instructor and the students are led to the diagnosis of the patient’s disease.

– Finally, as appropriate and if there is a definitive diagnosis, therapeutic options are discussed.

• The whole process of evaluating diverse findings and the consequent differential diagnosis are based on evidence-based medicine.
• Patient selection by the instructor is based on two criteria: (a) the lecture scheduled for the day and (b) the clinical significance of the patient’s disease. Certainly the analytical process and depth of the evaluation increase with time. The cases selected should be common diseases and situations of great clinical interest. The following is a list of diseases or syndromes / symptoms that the student should experience in order to contact at least one case of such a disease during the academic semester.

Diseases, or syndromes that the student must experience  

• Prolonged fever (Fever of Undetermined Origin-FUO)
• Infectious diseases (eg, fever, infectious endocarditis, leptospirosis, meningitis, leishmaniasis, severe sepsis, etc.)
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Pneumonia
• Pleuritis or pleural effusion
• Pulmonary embolism
• Heart failure – Atrial Fibrillation
• Coronary heart disease
• Pericarditis
• Arterial Hypertension – Stroke
• Upper or lower gastrointestinal bleeding
• Inflammatory bowel disease
• Jaundice
• Hepatitis
• Liver cirrhosis
• Ascites
• Acute cholecystitis or cholangitis
• Acute pancreatitis

General Abilities

The course aims to :

• Search, analyze and synthesize data and information, using the necessary technologies
• Decision making
• Independent work
• Teamwork
• Working in an interdisciplinary environment
• Promoting free, creative and inductive thinking

The sum of knowledge described is the curriculum and syllabus.

1. Infectious diseases 

1.1. Very important knowledge  

1.1.1. The concept of pathogenic microorganisms, their infectious potency and opportunistic infections.

1.1.2. Bacterial classification and pathogenic mechanisms of bacterial infections (particularly entry and colonization, infiltration, proliferation, defense mechanisms bypass).

1.1.3. Clinical Disease Induction: Toxins, bacterial proliferation, organism reaction.

1.1.4. What are the groups (and subgroups where available) of antibacterial drugs (antibiotics)? What are their main mechanisms of action, what are the mechanisms of resistance and by which mechanisms does resistance develop?

1.1.5. The importance of bacterial susceptibility and evaluation of in vitro susceptibility tests. Importance of the patient’s immune status and the location of the infection. Principles underlying the combined chemotherapy of infections.

1.1.6. Main groups of antibacterial drugs, modes of action, main side effects.

1.1.7. Clinical applications of individual antibiotics and antibiotic groups.

1.1.8. Virus classification and pathogenic mechanisms of viral infections (cell adhesion, entry into reproductive cells, dispersal)

1.1.9. What are the main antiviral drugs (other than antiretrovirals) and what are their main clinical signs?

1.1.10. General morphological classification of fungi. What are the main medications used in the treatment of systemic infections by fungi? What is their mechanism of action and the main clinical applications?

1.1.11. Pests (protozoa and helminths): Classification, pathogenic mechanisms of infection and immune response.

1.1.12. Infections in individuals with immune mechanisms disorders and in particular those with impaired humoral and cellular immunity.

1.1.13. Adult vaccines, (what they are, and what are the indications, contraindications, and complications) and passive immunization.

1.1.14. Chickenpox virus infections: Epidemiology, modes of transmission, pathogenesis, clinical presentation, and chickenpox complications. Pathogenesis, clinical presentation, specific localization and complications of zoster. Prevention and treatment of zoster virus infections.

1.1.15. Epstein Barr Infections: Epidemiology, mode of transmission, pathogenesis, clinical presentation, and in particular the clinical picture of infectious mononucleosis, laboratory findings, antibodies produced and diagnosis of the disease. The importance of the virus in the development of hematologic neoplasms.

1.1.16. Cytomegalovirus Infections: Epidemiology, modes of transmission, Cytomegalovirus monocytosis syndrome, Cytomegalovirus infections in the immunocompromised. Diagnosis and treatment of cytomegalovirus infections.

1.1.17. Influenza. Virological data (types of virus), epidemiology, modes of transmission, clinical presentation, complications, diagnosis, prevention and treatment of disease.

1.1.18. Retroviral infections and human immunodeficiency virus (HIV) infections: Virological data, modes of transmission and epidemiology, pathogenesis, clinical course of infection (acute syndrome, asymptomatic infection, early symptomatic infection). The latter includes neurological disease, secondary infections, neoplasms and other manifestations. Diagnosis (method and its application).

1.1.19. Pneumococcal infections. Microbiological data, pathogenesis, types of infections and correspondent clinical presentation and treatment.

1.1.20. Streptococcal infections. Microbiological data and classification of streptococci, epidemiology and description of clinical types of infections (scarlet fever, pharyngitis, erysipelas etc.). Complications and treatment.

1.1.21. Staphylococcal infections. Microbiological data, pathogenesis, susceptible populations, types of staphylococcal infections and treatment.

1.1.22. Infections by Gram Negative Intestinal Bacteria: Microbiological data and pathogenesis of related infections.

1.1.23. Infections by E. Coli: Epidemiology, clinical types of infection, diagnosis and treatment.

1.1.24. Non-typhoid salmonellosis. Microbiological data, epidemiology, clinical syndromes, diagnosis and treatment.

1.1.25. Brucellosis. Microbiological data, epidemiology, clinical syndromes, diagnosis and treatment.

1.1.26. Tuberculosis: Microbiological data, epidemiology, pathogenesis (innate and acquired immunity, initial lesion, post-primary tuberculosis). Description of the clinical presentation and course of primary and post-primary tuberculosis. Diagnosis of pulmonary tuberculosis. Tuberculin test (pathophysiological basis, evaluation). False negative tuberculin test and T cell anergy. Description of extra pulmonary forms of tuberculosis. Anti-tuberculous medications, principles that determine their administration and side effects. The Importance of BCG Vaccine and Chemoprophylaxis.

1.1.27. Leishmaniasis. Microbiological data and epidemiology, modes of transmission, clinical presentation and complications, diagnosis and treatment of visceral leishmaniasis.

1.2. Important knowledge 

1.2.1. Normal flora of the oral cavity and intestine

1.2.2. Defensive mechanisms against infections

1.2.3. Surface, physical and humoral barriers, non-specific immunity, specific immune mechanisms.

1.2.4. Rubella: Epidemiological data, transmission modes, clinical picture and complications (especially in pregnant women), diagnosis, prophylaxis.

1.2.5. Measles: Epidemiology, pathogenesis, modes of transmission, clinical picture and complications, diagnosis, treatment and prophylaxis.

1.2.6. Mumps. Epidemiology, modes of transmission, clinical picture, complications, management and prevention.

1.2.7. Infections by Neisseria meningitis. Microbiological data, epidemiology, Neisseria meningitis carrier stage and susceptible individuals, mode of transmission, pathogenesis, clinical syndromes, complications, treatment and prevention.

1.2.8. Legionellosis. Microbiology and epidemiology data, transmission mode, clinical manifestations, diagnosis, treatment.

1.2.9. Infections by intestinal Gram negative bacteria other than E. Coli: Which bacteria belong to this class and what infections do they cause?

1.2.10. Pseudomonas infections. Epidemiological data, clinical syndromes, diagnosis and treatment.

1.2.11. Shigellosis. Microbiological data, epidemiology and pathogenesis, clinical manifestations, treatment and prevention.

1.2.12. Campylobacter infections: Microbiological data, transmission modes, clinical spectrum of events, diagnosis and treatment.

1.2.13. Yersinia infections. Microbiological data, transmission modes, clinical spectrum of events, diagnosis and treatment.

1.2.14. Clostridia infections. Microbiological data, epidemiology, pathogenesis, clinical picture, tetanus diagnosis and treatment as well as prophylaxis, especially in injuries. Pathogenesis, clinical syndromes depending on the causative factor, clinical picture, diagnosis and treatment of botulism. Food poisoning and colitis caused by Clostridium difficile.

1.2.15. Mixed anaerobic infections. General characteristics of anaerobic infections in terms of penetration, pathogenesis and clinical manifestations. Clinical syndromes that cause or participate the anaerobic bacteria, diagnosis and treatment.

1.2.16. Leptospirosis. Microbiological data, epidemiology, mode of transmission, spectrum of clinical syndromes, complications, diagnosis, treatment.

1.2.17. Lyme disease. Microbiological data, epidemiology, mode of transmission, clinical manifestations in different disease stages, diagnosis and treatment.

1.2.18. Mycoplasma infections. Microbiological data, epidemiology, spectrum of clinical syndromes, diagnosis and treatment.

1.2.19. Amebiasis. Microbiological data, epidemiology, mode of transmission, spectrum of clinical syndromes, diagnosis by disease location, treatment.

1.2.20. Malaria. Microbiology data and parasite cycle. Pathogenesis and type of immunity to the parasite. Clinical syndromes, complications, diagnosis, treatment and prevention data.

1.2.21. Toxoplasmosis. Microbiology data, protozoan biological cycle, mode of transmission and pathogenesis of infections, spectrum of clinical syndromes (congenital toxoplasmosis, acquired toxoplasmosis in immunocompetent and immunosuppressed individuals), diagnosis and treatment.

1.2.22. Giardia lamblia infection: Microbiological data, epidemiology and susceptibility, clinical forms of infection, diagnosis and treatment.

1.3. Desired knowledge 

1.3.1. Herpes simplex virus infections (types of virus, mode of transmission, pathogenesis, spectrum of clinical manifestations, treatment).

1.3.2. Adenoviruses: Virological data, mode of transmission, main clinical syndromes.

1.3.3. Enteroviruses: Virological data and groups of enteroviruses. Epidemiology, pathogenesis, transmission modes and major clinical syndromes.

1.3.4. Viral respiratory infections. Epidemiological data major groups of pathogenic viruses and clinical syndromes.

1.3.5. Diphtheria: Microbiological data, transmission modes, epidemiology, pathogenesis, clinical presentation and complications, prognosis, diagnosis, treatment, prophylaxis.

1.3.6. Anthrax: Microbiological data, epidemiology, clinical syndromes, prognosis, treatment.

1.3.7. Listeriosis: Microbiological data, epidemiology, transmission modes, description of clinical syndromes in pregnant and non-pregnant women, diagnosis, treatment.

1.3.8. Hemophilus Influenzae Infections. Microbiology, epidemiology, transmission, clinical syndromes, management and prevention.

1.3.9. Pertussis: Microbiological data, epidemiology and pathogenesis of infection. Mode of transmission, clinical picture and complications. Diagnosis, treatment, prophylaxis.

1.3.10. Typhoid fever: Definition, mode of transmission, epidemiology, clinical picture and course, complications, prognosis, diagnosis and treatment.

1.3.11. Cholera: Microbiology, epidemiology, transmission modes, clinical picture and complications, diagnosis, prognosis and treatment.

1.3.12. Actinomycosis. Microbiological data, pathogenesis and predisposing factors, clinical syndromes, diagnosis and treatment.

1.3.13. Nocardia infections: Microbiological data, transmission mode, susceptible individuals, clinical syndromes, prognosis and treatment.

1.3.14. Rickettsial infections. Rickettsia groups and epidemiology, clinical picture, prognosis and treatment of the main infections.

1.3.15. Chlamydial infections. Microbiology data and infections caused by C. Trachomatis.

1.3.16. Psittacosis. Microbiological data, epidemiology, transmission modes, clinical picture, diagnosis, treatment.

1.3.17. Candidiasis: Microbiological data, pathogenesis, clinical manifestations (local and systemic), diagnosis and treatment.

1.3.18. Aspergillosis: Etiology, pathogenesis, clinical syndromes, diagnosis and treatment.

1.3.19. Clinical infections by Pneumocystis Carinii (jiroveci): Etiology, epidemiology, pathogenesis, clinical manifestations, course, prognosis and treatment.

1.3.20. Intestinal Trematodes (Helminthic) infections: Parasitology data, main parasites and the infections they cause, treatment.

1.3.21. Echinococcosis. Parasitology data, cyst morphology, manifestations depending on the affected organs, complications of cyst rupture. Diagnosis and treatment of echinococcal cyst.

1.3.22. Cysticercosis: Description of disease development and clinical-laboratory manifestations.

1.3.23. Intestinal Nematodes (Helminthic) Infections. Parasitology data and rough description of the diagnosis and treatment of ascariasis, infections from ancylostoma duodenale, trichuris trichiura and enterobius vermicularis (oxyuriasis).

1.4. Basic knowledge 

1.4.1. Vaccines: What are the vaccines and what infections do they cause.

1.4.2. Parvoviruses: What are parvoviruses and what is their significance.

1.4.3. Papovaviruses: Main Subgroups and Clinical Significance.

1.4.4. Rabies: Definition, epidemiology, mode of transmission, pathogenesis, clinical picture and prophylaxis.

1.4.5. Arboviruses: Modes of transmission, groups of induced clinical syndromes.

1.4.6. What infections do Moraxella cause?

1.4.7. Acinetobacter Infections: Their Importance in Hospital Infections.

1.4.8. Tularemia: Microbiology data, modes of transmission, main clinical syndromes.

1.4.9. Plague: Microbiology, transmission, main clinical syndromes.

1.4.10. Cat scratch disease: Etiology, epidemiology, clinical manifestations, diagnosis and treatment.

1.4.11. Leprosy: Modes of transmission, main clinical syndromes, diagnosis.

1.4.12. Q fever: Microbiology data, modes of transmission, clinical picture, diagnosis.

1.4.13. Histoplasmosis: Microbiology data, main clinical syndromes, diagnosis.

1.4.14. Coccidioidomycosis: Microbiology, main clinical features, diagnosis.

1.4.15. Blastomycosis: Microbiology data, main clinical syndromes, diagnosis.

1.4.16. Tissue nematodes infections: Thorough description of parasitology, mode of transmission and clinical manifestations of trichinosis and toxocariasis.

1.4.17. Filariasis: Epidemiological data and infections caused by filariae.

1.4.18. Trematodes Infections: Parasitology, epidemiology, pathogenesis, clinical manifestations of acute and chronic infection, diagnosis and treatment of schistosomal infections. Biliary and bile duct infections by trematodes.

2. Major microbial clinical syndromes 

2.1. Very important knowledge 

2.1.1. Systemic inflammatory reaction syndrome, sepsis: Definitions, pathogenesis, clinical picture description, diagnosis and treatment.

2.1.2. Acute microbial pharyngitis. Causes, clinical events by cause, complications, diagnosis, treatment.

2.1.3. Urinary tract infections: Definitions, etiology and predisposing factors, epidemiology, clinical-laboratory manifestations (asymptomatic bacteriuria, acute cystitis, acute pyelonephritis, urinary tract infections), diagnosis, basics of treatment.

2.1.4. Acute microbial gastroenteritis: Definition, epidemiology, causative agents, pathogenesis (importance of defense mechanisms and virulence factors of microbes as well as mechanisms of clinical disease), epidemiological forms, clinical manifestations and non-clinical manifestations principles of treatment.

2.1.5. Microbial endocarditis: Definition and classification. Causes and pathogenesis of indigenous valve endocarditis, addictive endocarditis and prosthetic valve endocarditis. Clinical and laboratory findings. Diagnostic criteria and diagnosis. Basic principles of treatment.

2.1.6 Bacterial meningitis: Causes, causal pathogenesis, clinical manifestations, physical findings, laboratory findings, and particular findings of cerebrospinal fluid. Diagnosis and principles of treatment. Special forms of bacterial meningitis (tuberculosis, syphilis, fungal etc).

2.1.7. Viral meningitis: etiological factors, clinical-laboratory manifestations, cerebrospinal fluid findings, diagnosis and treatment.

2.1.8. Nosocomial infections: Definition, frequency, most commonly pathogens, predisposing factors and major infections caused.

2.1.9. Fever of unknown etiology: Definitions, major groups of diseases with the main individual diseases appearing as fever of unknown etiology and diagnostic approach.

2.2. Important knowledge 

2.2.1. Erysipelas and cellulite: Definitions, etiology, clinical picture, diagnosis and treatment.

2.2.2. Sexually transmitted diseases. Which pathogens are sexually transmitted and what clinical syndromes they cause in the genitals or other systems.

2.2.3 Hematogenous Osteomyelitis: Definition, etiologic factors, manifestations of acute hematogenous osteomyelitis and vertebral osteomyelitis. Diagnosis and treatment.

2.2.4. Septic arthritis: How it is caused, predisposing factors, common pathogens, clinical picture, laboratory findings, diagnosis and treatment.

3. Cardiovascular diseases 

3.1. Very important knowledge 

3.1.1. Elements of normal cardiac function and in particular the importance of end diastolic tumors, atrial contraction, inotropic myocardial status and ventricular transport.

3.1.2. Definition, etiology and causative factors of heart failure.

3.1.3. Types of heart failure (CA): Systolic-diastolic CA, high-low-grade CA, right-left CA, front-to-back CA.

3.1.4. Symptoms (with emphasis on the types of dyspnea) and physical findings of heart failure.

3.1.5. Diagnostic criteria CA.

3.1.6. Cardiogenic pulmonary edema: Definition, pathophysiology, clinical picture, physical and imaging findings, diagnosis and treatment.

3.1.7. Reason and pathogenesis of ischemic heart disease. Typical clinical manifestations, electrocardiographic findings, and physical examination findings in stable angina. Diagnostic approach to stable angina (fatigue test, thallium fatigue test). Prognosis of stable angina. Stable angina treatment (Health measures, risk factors treatment and treatment). How is unstable angina and Prinzmetal angina defined?

3.1.8. Acute myocardial infarction: Pathogenesis and clinical presentation. Objective, electrocardiographic and laboratory findings of the infarction. Treatment before hospitalization, initial hospitalization, the importance of fibrinolysis and invasive myocardial resuscitation. A brief description of the major complications of heart attack.

3.1.9. Definition, etiology, clinical manifestations and physical findings of acute pericarditis. Diagnostic access. How is pericardial epilepsy defined, what are the common causes, symptoms, physical findings and treatment of epilepsy.

3.1.10. How it is defined, what the prevalence is and how hypertension is classified.

3.1.11. Description of the predisposing factors of idiopathic hypertension.

3.1.12. What are the natural history and effects on target organs of arterial hypertension?

3.1.13. Causes of secondary arterial hypertension and diagnostic approach.

3.1.14. Dietary measures to treat arterial hypertension. Arterial hypertension medications. Groups of antihypertensive drugs, their mode of action and side effects. Arterial hypertension principles.

3.1.15. Malignant hypertension: How it is defined, pathogenesis, main symptoms, treatment.

Venous thrombosis: Predisposing factors, ways of diagnosis and treatment of venous thrombosis. Prevention of venous thrombosis.

3.2. Important knowledge 

3.2.1. Definition, pathogenesis, epidemiology, clinical laboratory image of rheumatic fever.

3.2.2. Etiology, pathophysiology, clinical manifestations and complications, physical findings and diagnosis of valvular diseases.

3.2.3. Elements of physiology and pathophysiology of pulmonary circulation.

3.2.4. Pulmonary hypertension: Definition, conditions causing it, pathophysiology, diagnostic approach. Natural history of primary pulmonary hypertension.

3.2.5. Pulmonary heart due to pulmonary embolism (acute and chronic). Clinical laboratory findings of pulmonary heart disease in patients with chronic obstructive pulmonary disease and restrictive lung disease.

3.2.6. Pathogenesis (lipoprotein accumulation and modification, leukocyte role and foam cell formation), progression and atherosclerotic complications. Predisposing atherosclerotic agents, triggering clinical syndromes and prevention (blood lipid lowering and antihypertensive treatment).

3.2.7. Aortic aneurysms, definition, underlying diseases and natural history. Definition, clinical appearance, diagnosis and treatment of aortic aneurysm resection.

3.3. Desired knowledge 

3.3.1. Chronic pericardial collections: Where they may be due, clinical events, diagnosis.

3.3.2. Chronic compressive pericarditis: Clinical manifestations and physical findings.

4. Respiratory Diseases

4.1. Very important knowledge 

4.1.1. Chest X-ray evaluation (plain chest and computed tomography) and in particular in imaging of atelectasis, thickening, reticular pattern, nodular lesions, synovial lesions, lateral collection and medullary tumors.

4.1.2. Ways to control respiratory function: Definitions and significance of parameters of dynamic spirometry, static tumors and lung diffusion.

4.1.3. Evaluation of blood gas values

4.1.4. Laboratory tests for sputum (Gram staining, common cultures, specific stains and cultures, cytological examination). Applications and clinical significance.

4.1.5. Main indications and contraindications of bronchoscopy (diagnostic and therapeutic). Main complications.

4.1.6. Indications for chest compressions, lateral fluid examinations and their evaluation.

4.1.7. Definition, frequency and epidemiology, classification, pathogenesis and pathophysiology of bronchial asthma. Factors that cause or contribute to the development of asthma. Clinical features and classification of bronchial asthma according to them. Diagnosis of bronchial asthma, groups of anti-asthma drugs (including mode of action and side effects) and principles of medication for asthma treatment (acute and chronic).

4.1.8. Chronic Obstructive Pulmonary Disease (COPD): Definition of the disease as well as definitions of chronic bronchitis and emphysema. Epidemiology, description of etiologic factors and pathophysiology of COPD. Clinical manifestations, objective spirometry and imaging findings depending on the prevalence of chronic bronchitis or emphysema. Diagnosis and treatment of COPD.

4.1.9. Causes and manifestations of acute bronchitis.

4.1.10. By what defense mechanisms does the lower respiratory tract become sterile and what are the mechanisms of entry of germs into it. Conditions predisposing to the entry of pathogens.

4.1.11. Classification of pneumonia according to the etiology, etiologic factors and the particular circumstances of the development of the infection.

4.1.12. Out-of-hospital pneumonia: Most common pathogens, clinical picture and laboratory findings as well as distinguishing between typical and atypical pneumonia. Induction mechanisms and characteristic aspiration pneumonia. In which infectious diseases pneumonia is part or main manifestation of it in specific endemic areas. Causes and clinical significance of recurrent pneumonia.

4.1.13. Investigation of pneumonitis based on epidemiological data, history, clinical picture, laboratory findings and in particular imaging findings, sputum examination and serological tests.

4.1.14. What are the main complications of pneumonia and what are their main laboratory and imaging features?

4.1.15. How the pulmonary abscess is defined and the pulmonary abscess classification? In what cases does the pulmonary abscess develop from the absorption of oropharyngeal secretions, what pathogens are involved and what the natural history of the disease?

4.1.16. Experimental treatment of out-of-hospital pneumonia according to the age and underlying diseases of the patients. Clinical laboratory data supporting the admission of patients with pneumonia to hospital. Treatment of cases of pneumonia admitted to hospital according to the severity and criteria of severe pneumonia. Treatment of anaerobic pneumonia and abscesses. Prognosis of different forms of pneumonia.

4.1.17. Interstitial lung diseases: how they are defined, what pathogenetic processes are involved, what are the most common forms. Clinical laboratory and imaging research (history, clinical presentation, environmental history, physical and imaging findings, findings of functional pulmonary tests and blood gases). Importance of pulmonary biopsy.

4.1.18. Rationale and predisposing factors for pulmonary embolism. Pathophysiological disorders of the respiratory and circulatory system. Clinical manifestations depending on the extent of embolism. Diagnostic approach to pulmonary embolism (radiological findings, hematopoietic-ventilation scintigraphy, high-resolution computed tomography, angiography). Treatment of pulmonary embolism.

4.1.19. Acute respiratory distress in adults: Definition, frequency and main causes. Pathogenesis, pathophysiology, clinical manifestations, physical and imaging findings, blood gas disorders, diagnosis and basic principles of treatment.

4.1.20. Reason, laboratory and imaging investigation, diagnosis and differential diagnosis of pleural effusions.

4.2. Important knowledge 

4.2.1. Definition, frequency, etiology (congenital and permissible causes), pathologic features, clinical manifestations, diagnostic tools and treatment of bronchiectasis.

4.2.2. Gross pathological anatomy and pathophysiology of interstitial pulmonary fibrosis. Clinical picture (symptoms and physical findings), radiological and spirometry findings of the disease. Prognosis, diagnosis and treatment of interstitial pulmonary fibrosis.

4.2.3. Definition, pathogenesis, pathophysiology, clinical manifestations during sleep and during alertness, and diagnosis of sleep apnea syndrome. Diagnosis and treatment of the syndrome.

4.2.4. Definition, Types, Common Causes and Clinical Characteristics of Respiratory Failure.

4.2.5. Indications for oxygen therapy in acute and chronic conditions. O2 administration systems and O2 toxicity.

4.2.6. Usual medullary tumors depending on location.

4.2.7. Causes, clinical manifestations, physical and imaging findings and treatment of pneumothorax.

4.3. Desired knowledge 

4.3.1. Definition, frequency and epidemiology, pathological physiology and molecular genetics, clinical manifestations and development of cystic fibrosis. Diagnostic criteria and principles of treatment.

4.3.2. Etiology, pathology and clinical picture of hypersensitivity pneumonitis (exogenous allergic cellulitis, eosinophilic pulmonary syndromes). Diagnostic approach and treatment.

4.3.3. Bronchiolitis definition and classification. Clinical picture, imaging findings and diagnosis of obstructive bronchitis with organizational pneumonia.

4.3.4. Definition and common causes of under-ventilation, pathophysiology, clinical, laboratory findings, gas exchange control findings, and diagnosis.

4.3.5. Hyperventilation Syndrome: Definition, common causes, clinical features, pathophysiology and diagnosis.

4.4. Elementary knowledge 

4.4.1. Indications for bronchial alveoli. What is it, what data are being tested and what is the clinical utility.

4.4.2. Definition, main clinical and imaging features of decolorizing interstitial pneumonia, pharmaceutical interstitial pneumonitis, pulmonary cellular proteinuria, Langerhans cell pulmonary histiocytosis, lymphocytic cell lymphocytes and lymphocytic invasive cells.

4.4.3. What are the main occupational lung diseases, what clinical manifestations and how they are being investigated.

4.4.4. Acute mesothelial inflammation: Frequency, causes, laboratory and imaging findings.

Gastrointestinal tract diseases 

5.1. Very important knowledge 

5.1.1. Main indications, main contraindications, and major complications of upper gastrointestinal, lower gastrointestinal endoscopic control, and reciprocal cholangiopancreatography endoscopy.

5.1.2. Definition and causes of malnutrition.

5.1.3. Gastroesophageal reflux disease: Definition, epidemiology, etiology, pathogenesis, clinical manifestations and complications, diagnosis and treatment.

5.1.4. Elements of stomach physiology.

5.1.5. Epidemiology, pathophysiology, diagnosis and treatment of Helicobacter pylori stomach infection.

5.1.6. Definitions, epidemiology, etiology and pathogenesis of peptic ulcer. Clinical manifestations of duodenal and gastric ulcer. Complications of ulcers (bleeding, perforation, stenosis). Diagnosis and conservative treatment of peptic ulcer. Indications for surgical treatment.

5.1.7. Definition, classification and clinical picture of acute, chronic and specific forms of gastritis

5.1.8. Elements of small bowel physiology.

5.1.9. Malabsorption syndromes. Definition, etiology, general clinical manifestations and specific events depending on the cause, clinical trial documenting the diagnosis and underlying disease.

5.1.10. Celiac disease: Epidemiology and etiology of the disease. Basic pathologic picture and common causes of atrophy of the tubercles. Clinical-laboratory events, complications and diseases often associated with celiac disease. Diagnosis and treatment of the disease.

5.1.11. Hypocalcaemia (Epidemiology, clinical features, diagnosis and treatment).

5.1.12. Constipation: Definition, main causes and investigation. Where and how to treat idiopathic constipation.

5.1.13 Inflammatory enteropathies. Classification.

5.1.14. Inflammatory Bowel Diseases: Definition, epidemiology, basic pathologic anatomical features of ulcerative colitis and Crohn’s disease etiology, pathogenesis.

5.1.15. General symptoms, specific symptoms, intestinal complications and extraintestinal manifestations of Inflammatory Bowel Diseases. Clinical forms of ulcerative colitis and Crohn’s disease.

5.1.16. Investigation of Inflammatory Bowel Diseases (especially endoscopic and radiological findings), their prognosis, diagnosis and treatment.

5.1.17. Colon Diverticulosis: Definition, etiology, epidemiology and natural history. Clinical picture, physical findings, and complications of diverticulitis. Diagnosis, Complications and Treatment of diverticulitis.

5.1.18. How they are defined, how they are macroscopically distinguished, and what the histopathology of the colon polyps is.

5.1.19. Upper gastrointestinal Bleeding: Frequency, Main Causes, Clinical Laboratory Assessment (Background, Physical Findings, Clinical Trials), Immediate Treatment.

5.1.20. Lower gastrointestinal bleeding: Reason and diagnostic approach.

5.2. Important knowledge 

5.2.1. Definition, symptoms, diagnostic approach and treatment of esophageal achalasia.

5.2.2. Infectious esophagitis: Which pathogens cause the disease, what their endoscopic appearance is.

5.2.3. The concept of dyspepsia, subgroups of dyspepsia, epidemiology, diagnosis and treatment of functional dyspepsia.

5.2.4. Chronic intestinal pseudo-obstruction. Causes. pathogenesis, clinical manifestations, diagnosis and treatment.

5.2.5. Adenomatous (neoplastic) colon polyps: Definition, frequency, clinical relevance, symptoms, diagnosis, treatment and monitoring.

5.2.6. Main causes, clinicopathological manifestations, imaging findings and treatment of acid majolica.

5.2.7. Classification, etiology and predisposing factors of forms of intestinal ischemia. Clinical picture of embolism and thrombosis of the mesenteric arteries and thrombus of the mesenteric vein. What are the hematological and biochemical alterations of acute ischemia and imaging methods that help diagnosis. Chronic bowel ischemia. Treatment and prognosis of acute and chronic mesenteric ischemia.

5.2.8. Ischemic Colitis. Frequency, etiology, clinical picture, diagnostic approach and treatment.

5.3. Desired knowledge 

5.3.1. Spastic disorders of the esophagus, mainly of their importance and clinical picture.

5.3.2. Esophageal foreign bodies: High risk individuals, clinical manifestations.

5.3.3. Causes of bacterial overgrowth in the small intestine, clinical manifestations, diagnostic methodology and management.

5.3.4. Polyps, other than neoplasms, of the large intestine: Definition and clinical significance.

5.3.5. Familial adenomatous polyps. Pathogenesis of the disease, variants, symptoms, treatment and control of the patient’s relatives.

5.3.6. Short bowel syndrome: As defined, pathophysiology depending on the area removed, clinical picture and management.

5.3.7. Enteropathy with loss of albumin. Main causes, clinical-laboratory characteristics and management.

5.3.8. How is it defined, what is the frequency and pathogenesis, what clinical forms does it present, how is the diagnosis documented, and how is the congenital adult treated?

5.3.9. Rectal diseases and in particular, hemorrhoids, stretch marks, abscesses and perianal fistulae.

5.4. Elementary knowledge 

5.4.1. Gastrointestinal tract tests: esophageal and esophagus manometry.

5.4.2. Secondary esophageal motor disorders: Clinical manifestations and related diseases.

5.4.3. Types and manifestations of esophageal aberrations.

5.4.4. Clinical appearance and differential diagnosis and investigation of esophageal rupture.

5.4.5. Causes (and individual diseases and conditions) of delayed gastric emptying, range of clinical manifestations, physical examination findings and treatment.

5.4.6. Definition, causes, diagnosis and treatment of tropical Sprue

5.4.7. Causes, clinical-laboratory manifestations, and ways of diagnosing lymphangiectasia.

5.4.8. What is the cause, what are the main events, how is it diagnosed and what is the treatment of Whipple’s disease?

5.4.9. How it is defined, what clinical manifestations, how to diagnose and treat eosinophilic gastroenteritis.

5.4.10. Small intestinal exudates: In what forms of the intestine is it diagnosed and its complications.

5.4.11. Radiation associated enteritis: How it manifests clinically

5.4.12. Familial polyposis: How it is defined, how it is inherited, what the underlying genetic pathogenesis is and what variants of the disease. Symptoms, diagnosis and treatment.

5.4.13. Hamartomatous Polyps and Associated Syndromes. Clinical manifestations and inheritance.

6. Diseases of the liver, biliary tract and pancreas 

6.1. Very important knowledge 

6.1.1. What is bilirubin, what forms exist and being measured, what form is filtered in the urine and what is the interpretation of its increase in serum and in the urine.

6.1.2. What is the significance of the increase in aminotransferases, LDH, alkaline phosphatase and γGT in liver and biliary diseases and how this elevation is evaluated.

6.1.3. What are the benefits and how are serum albumin levels and prothrombin time measured in liver diseases.

6.1.4. What is the utility of measuring serum amylase and lipase in pancreatic diseases and in what other conditions are elevated amylase values.

6.1.5. Imaging methods of liver, biliary and pancreatic control with emphasis on ultrasound, computed tomography of the upper abdomen, endoscopic palindromic cholangio-pancreatography, and magnetic cholangio-pancreatography.

6.1.6. Main indications and complications of liver biopsy.

6.1.7. Jaundice: Definition, classification based on the superiority of unconjugated or conjugated bilirubin (often causes and diagnostic access). Laboratory distinction of hepatocellular carcinoma with obstructive jaundice.

6.1.8. Definition, most common causes, clinical picture, laboratory findings, liver and extrahepatic complications, prognosis, treatment and monitoring of acute hepatitis.

6.1.9. Hepatitis A. Virus Infection A. Elements of virology, modes of transmission, serological diagnosis and prophylaxis.

6.1.10. Hepatitis B virus infection. Virology elements, modes of transmission, high risk groups, clinical picture and outcome. Serological and virological markers that diagnose and prevent the disease.

6.1.11. Hepatitis C virus infection Virology, epidemiology, transmission, clinical picture and outcome of the disease, favorable or unfavorable factors involved in the progression of the disease. Diagnosis based on biochemical tests, serological and virological control and disease prevention.

6.1.12. Definition, histological forms and scoring system for chronic viral hepatitis.

6.1.13. Chronic hepatitis B: The spectrum of clinical manifestations and stages of the natural history of chronic hepatitis B. Laboratory investigation (serological and virological findings) of the disease.

6.1.14. Chronic hepatitis C: The spectrum of clinical manifestations and stages of the natural history of chronic hepatitis B. Laboratory investigation (serological and virological findings) of the disease.

6.1.15. Prognosis and treatment of chronic hepatitis B and C.

6.1.16. Epidemiology and risk factors in alcoholic liver disease. Pathogenesis and histopathological forms of alcoholic liver disease. Clinical manifestations, laboratory findings, diagnosis and complications of individual forms of alcoholic liver disease.

6.1.17. Definition, classification and causes of acute liver failure. Clinical and laboratory findings, treatment and prognosis of acute hepatic insufficiency.

6.1.18. Definition of morphological and etiological classification of liver cirrhosis. Clinical picture by disease phase and Child-Pugh gravity classification. Laboratory findings and treatment of cirrhosis.

6.1.19. Hypertensive hypertension. Definition and justification depending on the location of the cause.

6.1.20. Clinical and clinical laboratory findings of portal hypertension. What are gastroesophageal varices and congestive gastropathy? What are the prognostic indicators of impending varicose veins. Prophylactic treatment, treatment for active varicose veins and relapse prevention.

6.1.21. Pathophysiological mechanisms of ascites development. Causes of ascites based on diseases that affect or do not affect the peritoneum. Symptoms and clinical signs. Diagnosis of the presence of ascites collection. Biochemical and cytological analysis of ascites fluid, ascites classification to or not due to portal hypertension. Treatment of ascites depending on the type of ascites fluid.

6.1.22. Hepatic (systemic) encephalopathy. Definition, staging and differential diagnosis of other forms of cerebral dysfunction, predisposing factors in the development of the syndrome. Therapeutic measures.

6.1.23. Definitions, pathogenesis and risk factors for gallstones.

6.1.24. Etiology, pathogenesis, clinical picture, complications, laboratory findings, diagnosis and treatment of acute cholecystitis.

6.1.25. Definition of etiology, pathogenesis, clinical picture, laboratory findings, complications, diagnosis and treatment of acute cholangitis.

6.1.26. Definitions, Severity assessment criteria (Ranson’s) of Acute Pancreatitis. The concept of various forms of acute pancreatitis depending on the presence or not of necrosis, fluid, blood and abscess.

6.1.27. Pathogenesis and predisposing factors for acute pancreatitis.

6.1.28. Symptoms, physical findings, laboratory findings and imaging findings in acute pancreatitis.

6.1.29. Diagnosis, systemic and complications of acute pancreatitis. Prognosis and therapeutic interventions in acute pancreatitis.

6.2. Important knowledge. 

6.2.1. Hepatitis D Virus Infections: Causes of Infection, Frequency, Clinical Forms Diagnosis

6.2.2. Non-alcoholic Fatty Liver Disease – Metabolically Associated Fatty Liver Disease: etiology, clinical manifestations, laboratory findings, prognosis and treatment.

6.2.3. Classification by etiology and histology of medicinal liver diseases.

6.2.4. Primary biliary cholangitis (cirrhosis). Definition, epidemiology, correlations with other autoimmune diseases, range of clinical-laboratory manifestations, histological findings, diagnosis prognosis and treatment of the disease.

6.2.5. Budd-Chiari Syndrome: How it is Defined, Main Causes, Clinical Laboratory Events, Diagnosis and Treatment.

6.2.6. Clinical and laboratory findings, diagnosis and treatment of chronic cholecystitis.

6.3. Desired knowledge 

6.3.1. Epidemiology, clinical picture and clinical forms, laboratory and serological findings, classification based on serological findings, diagnosis and treatment of autoimmune hepatitis.

6.3.2. Chronic pancreatitis: Definition, classification, epidemiology, clinical picture and laboratory findings, diagnosis, complications and management.

6.3.3. Endocrine tumors of the pancreas. Who are they, what hormones they secrete, where they are usually detected where appropriate, what their clinical manifestations are.

6.4. Elementary knowledge 

6.4.1. Hepatitis E and G / GB-C Infections: Transmission Modes, Frequency and Clinical Significance.

6.4.2. Α1-antitrypsin deficiency: mode of inheritance, genetic basis, pathogenesis, affecting organs and clinical manifestations, diagnosis and treatment.

6.4.3. Hepatopulmonary Syndrome: Definition, frequency, pathogenesis, clinical picture and diagnostic criteria, prognosis and treatment.

6.4.4. Liver Syndrome: What are the main disorders of the lung parenchyma in cirrhosis, pathophysiology, manifestations and treatment.

6.4.5. Primary sclerosing cholangitis: Frequency, clinical picture, laboratory findings, diagnosis.

– Suggested Bibliography:

1. Cecil Basic Pathology

(Andreoli Thomas, Carpenter Charles, Griggs Robert)

ISBN 978960372176-5 K. & N. LITSAS OE

2. Basic diagnostic and therapeutic guide

(Tierney Lawrence M., Saint Sanjay, Thompson Clinton E., Whooley Mary A.)

ISBN 9789603998099 BROKEN HILL PUBLISHERS LTD

3. Internal Pathology Mayo clinic

(Thomas Habermann)

ISBN 978-960-6894-43-5 HAVALES A – HATZISSIMON K OE

4. HARRISON Internal Pathology

(D. KASPER, E. BRAUNWALD, A. FAUC I, S. HAUSER, D. LONGO L. JAMESON)

ISBN 978-960-394 684-7 PARISIAN PUBLISHER

5. Johns Hopkins Internal Medicine Board Review

(Bimal Ashar, Redonda Miller, Stephen Sisson)

Elsevier, 5^th ed. ISBN 978-0-323-37733-1

6. Medical Bibliography on the Internet

(PubMed and other bibliographic sources) 

– Related scientific journals :

1. The New England Journal of Medicine
2. The Lancet
3. Annals of Internal Medicine
4. JAMA Internal Medicine