So I am back at the VA.  I joined my team yesterday, and will round through July 15.  The first day of a rotation involves getting to know everyone and setting expectations.  We were admitting for the past 24 hours so today I expect to see a large number of patients.

I probably went a bit crazy with my teaching yesterday.  My excitement was probably out of control.  We have 2 enthusiastic, bright and green 3rd year students.  Every topic opens a new window to medicine.

While we covered many topics (probably too many), I will focus today on syncope.  When the team presented the patient to me, they had not taken an adequate syncope history.  As I wrote yesterday, we have an obligation to develop a complete and careful history for each problem.  So I went to the bedside and demonstrated.

The patient only complained of feeling like he was going to “pass out” when arising from his bed.  He denied palpitations at any time.

The team had not checked orthostatic blood pressures.  Of course, we had a constructive discussion of this problem.  Today I will follow up with orthostatic pressures and whether he has a pulse change.  I predict on pulse change because I am betting that he will have orthostasis (because of his history) secondary to autonomic dysfunction (because of his diabetes).

In the team’s defense, I saw the patient soon after admission so they had not had time to consider all the problems. The patient’s main reason for admission is not his “syncope” and they had done a great job on the main problem.

I thought this was an important teaching moment because a syncope diagnosis starts first with a careful history and physical.  Obviously this gave me a chance to focus on that point.