Station 64
Emily Taylor
Age: 15 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset and duration of dizziness
- Clarify the nature of dizziness — is it light-headedness or a spinning sensation (vertigo)?
- Ask how long each episode lasts
- Ask about triggers — does it occur when standing from sitting, during prolonged standing, or with exertion?
- Ask about frequency and whether symptoms are worsening
- Ask about associated symptoms including palpitations — clarify exactly when they occur, particularly in relation to standing, to assess for Postural Orthostatic Tachycardia Syndrome (POTS)
- Ask about chest pain or shortness of breath during the episodes
- Ask if any episodes of syncope or collapse have occurred — if so, how many and whether any injuries were sustained
- Ask if symptoms occur during exercise — if yes, this is a red flag and should prompt urgent referral to cardiology
- Ask about other symptoms such as nausea, vomiting, bowel or urinary changes, and general wellbeing
- Ask about menstrual history and whether there is any chance of pregnancy
- Explore the impact of symptoms on daily life and school performance
- Ask about hydration, diet, and fluid intake
- Take a psychosocial history including who she lives with, smoking, alcohol, and any recreational drug use
- Give diagnosis of possible postural orthostatic tachycardia syndrome
Example of explanation to patient
Emily, thank you for sharing everything so clearly, it really helps. From what you’ve described, it sounds like you may have a condition called Postural Orthostatic Tachycardia Syndrome, or POTS for short. Postural tachycardia syndrome, or PoTS, is a condition where your heart beats much faster than normal when you stand up. This can make you feel dizzy, light-headed, or even faint. Thankfully, it is not life-threatening, but it can interfere with your daily life and activities
The next step is for you to come in so we can check your blood pressure and heart rate while you’re sitting and standing and have a listen to your heart. I would also like to do some blood tests and an electric tracing of your heart (ECG) to rule out anything else. Is that something you’d feel okay with?
If the results point towards POTS, we’ll refer you to a heart specialist (paediatric cardiologist). They can help with long-term management and might suggest things like medication if needed, but often, lifestyle changes can really help too.
In the meantime, there are things you can start doing to feel better, like drinking plenty of fluids during the day, avoiding standing for too long, and standing up slowly. Light, regular activity like walking can also help, but if you feel dizzy or unwell, stop straight away.
I can also write a letter to your school, so they’re aware of what’s going on and can support you, especially with your GCSEs coming up. Would that be okay?
It is understandable to feel anxious, and sometimes stress can make symptoms worse, so making sure you’re supported at school is just as important as anything else.
Does that all make sense so far? Is there anything you’d like me to explain again or anything you’re worried about?
Management
Management
- Offer a face-to-face appointment to examine the patient, check pulse and blood pressure sitting and standing, and listen to the heart for any murmurs
- Postural Orthostatic Tachycardia Syndrome (POTS) is more likely if there is a sustained rise in heart rate of ≥30 bpm (or ≥40 bpm in those aged 12–19) within 10 minutes of standing, in the absence of orthostatic hypotension
- Offer blood tests including thyroid function, U&Es, LFTs, FBC, cortisol, and ferritin
- Offer a 12-lead ECG to rule out arrhythmia or structural abnormalities
- Advise the patient to keep a symptom diary to identify potential triggers
- Recommend increasing fluid intake to 2–2.5 litres per day, avoiding prolonged standing, and rising slowly from sitting or lying down
- Suggest compression stockings if symptoms are significant or persistent
- Encourage gentle, regular exercise such as walking, but advise stopping immediately if symptoms arise during activity
- Offer to refer the patient to a paediatric cardiologist for further evaluation and management after baseline investigations are completed — they may consider medications such as fludrocortisone or SSRIs.
- Offer a letter of support for the school to facilitate reasonable adjustments during GCSE preparation, helping to reduce anxiety around exam preparation and avoid symptom triggers
- Safety-net: advise the patient to seek urgent medical attention if symptoms worsen, if chest pain develops, or if dizziness occurs during exercise.
Learning point from this station:
Postural Orthostatic Tachycardia Syndrome (PoTS) is an important and often under-recognised cause of dizziness, palpitations, and fainting in adolescents, especially females. It is defined by a sustained rise in heart rate of ≥30 beats per minute (or ≥40 bpm in those aged 12–19) within 10 minutes of standing, without orthostatic hypotension. The standing heart rate is often >120 beats per minute in affected individuals.
Diagnosis is clinical, supported by postural heart rate and blood pressure measurement. ECG and baseline bloods help to exclude other causes such as arrhythmia, anaemia, or thyroid dysfunction.
Management is largely non-pharmacological, focusing on fluid intake, gradual postural changes, and lifestyle modifications. Severe or persistent symptoms may require referral to a paediatric cardiologist for further management, including possible pharmacological treatment.
It is essential to consider the impact on education and wellbeing, particularly in the context of school exams. Supporting the young person with school adjustments and reducing anxiety may help improve symptom control and quality of life.