A 19-year-old girl was admitted to our hospital with nausea, vomiting, hiccups, constipation and syncope. After hiccups or vomiting sinus arrest developed and lasted more than 5-8 seconds. She lost consciousness every one hour. Based on an electrocardiographic diagnosis of sick sinus syndrome (SSS), a temporary pacemaker was implanted. The next day, although her syncope and bradycardia disappeared, she had orthostatic tachycardia of over 120 beats/minute and swelling of the legs, which led to a diagnosis of postural orthostatic tachycardia syndrome (POTS). Neurologically, she showed the right-sided tongue deviation and parasympathetic system disorders revealed by coefficient of variation of R-R interval (CV_R-R), the Achner eye-ball pressure test, the valsalva ratio, and the head-up-tilt test. Brain MRI disclosed a small hyperintense lesion on a T2-weighted image with gadolinium enhancement in the right dorsal medulla including the hypoglottis nucleus and the posterior nucleus of vagus. After steroid pulse therapy (methyl prednisolone 1 g/day×3 days, 5 times) was administered, this lesion became smaller and finally disappeared. Before the lesion disappeared, she was able to begin rehabilitation by wearing elastic stockings and treatment with midodrine hydrochloride. The following year, she developed other MRI-proven brain lesions, suggestive of demyelination. Such a spinal and temporal distribution of lesions led to a diagnosis of multiple sclerosis (MS). A case of POTS caused by MS has not been reported previously, however, MS often affects the medullary paraventricular regions associated with autonomic failures. Autonomic failures often prevent patients from experiencing early rehabilitations. We should promptly give symptomatic treatment against autonomic failures, which leads to good patient recovery not only in patient vitality but also functionality.

Objective: A hospital Formulary (HF) is useful not only for providing a list of formulary drugs, but also for drug safety management and clinical practice in hospitals.  Our Pharmacy Division serves as a clinical training facility for the Faculty of Medicine and offers a bedside learning (BSL) program that allows students to participate in medical services.  Providing medical students with a requisite understanding of pharmacotherapy in order to effectively provide medical services is the goal of the core curriculum of medical education and HF use in BSL may be effective in achieving this goal.  We conducted a survey in order to examine the usefulness of an HF for medical students during clinical training and to determine what drug information is required by students.
Methods: Between April 2012 and March 2013, a questionnaire survey was conducted on 88 fifth-year medical students    who participated in a 1-day BSL program using an HF.
Results: The response rate was 100%.  All students responded that they understood how to use the HF and believed it was useful in BSL.  However, the level of satisfaction with the explanatory notes was significantly lower than that of other sections providing clinically useful additional information such as monographs or supplementary tables (p<0.05).  More than 80% of the students considered monographs to be useful for obtaining information on side effects, warnings and contraindications, dosage and administration, indications, dosing in renal impairment, and drug name.  Students generally considered supplementary tables useful for obtaining information on serious side effects and their early identification, points of drug use in renal dysfunction, appropriate drug use in cancer chemotherapy, insulin and diabetes treatment, calculations of pediatric dosing, and a list of clinically used abbreviations.
Conclusion: These results suggest that medical students believe an HF is useful in BSL.  When medical students participate in pharmacotherapy during BSL programs outside the Pharmacy Division, an HF that not only lists drugs but also contains supplementary tables of clinically useful information may be required.