[21M] With chronic dizziness and presyncope

Patient Description

A 21-year-old male has been experiencing chronic lightheadedness and presyncope for about three months. The symptoms are moderate but can sometimes feel severe and are present almost all day. They are triggered by activities such as driving, eating a meal, and being in public. The patient finds some relief by distracting himself or pushing through the symptoms. The dizziness came on both suddenly and gradually, depending on the day, and is triggered by certain head positions, eye movements, and worrying about the symptoms. The patient experienced significant stress about a month or two before the symptoms started. Blood pressure and heart rate can be elevated during episodes of dizziness. The patient has experienced palpitations or irregular heartbeats but no chest pain or discomfort. He sometimes has tension headaches and possibly migraines. Vision can be blurry or fuzzy with floaters but is functional. Occasional numbness or tingling in the hands and feet and difficulty with balance or coordination are also reported. The patient has a history of an irregular heartbeat, confirmed by a normal ECG. He uses nicotine a couple of times a day through vaping and chewing. His diet consists of half healthy food and half junk food, with an irregular meal schedule. He tries to stay hydrated, sometimes with electrolytes. Past medical history includes a migraine with aura about six months ago, wisdom teeth removal about a year ago, and involvement in a car accident about three years ago. He is not currently taking any medications and has no family history of heart disease, stroke, or other cardiovascular issues.

Arora's Assessment

What might be happening

Based on the symptoms and history you've provided, here are some possible explanations for your condition:

1. Orthostatic Hypotension

Rationale: Your symptoms of lightheadedness, feeling like you could faint, and wobbly sensation, especially when standing or changing positions, could be due to orthostatic hypotension. This condition occurs when your blood pressure drops significantly upon standing, leading to reduced blood flow to the brain.
Typical Treatments/Testing: Diagnosis often involves measuring blood pressure and heart rate changes when moving from lying down to standing. Treatment may include increasing fluid and salt intake, wearing compression stockings, and sometimes medications.

2. Anxiety or Panic Disorder

Rationale: The fact that your symptoms worsen in public and during stressful situations, along with your history of significant stress, suggests that anxiety or panic disorder could be contributing to your symptoms.
Typical Treatments/Testing: Diagnosis is usually clinical, based on your symptoms and history. Treatment may include cognitive-behavioral therapy (CBT), medications like SSRIs, and lifestyle modifications.

3. Cardiac Arrhythmia

Rationale: Your history of an irregular heartbeat and palpitations, along with dizziness and elevated heart rate, could indicate a cardiac arrhythmia. Even though your ECG was normal, intermittent arrhythmias can sometimes be missed.
Typical Treatments/Testing: Further cardiac evaluation, such as a Holter monitor or event monitor, may be needed. Treatment depends on the type of arrhythmia and may include medications, lifestyle changes, or procedures like ablation.

4. Vestibular Disorders

Rationale: Your symptoms of dizziness triggered by certain head positions and eye movements could be related to a vestibular disorder, such as benign paroxysmal positional vertigo (BPPV) or vestibular migraine.
Typical Treatments/Testing: Diagnosis may involve a physical examination and specific maneuvers to trigger symptoms. Treatment can include vestibular rehabilitation exercises, medications, and lifestyle changes.

What you can do

Orthostatic Hypotension

Stay Hydrated: Drink plenty of fluids, especially water. Consider adding electrolytes to your drinks.
Diet: Increase your salt intake if recommended by your doctor.
Compression Stockings: Wear compression stockings to help improve blood flow.
Slow Movements: When changing positions, do so slowly to give your body time to adjust.

Anxiety or Panic Disorder

Relaxation Techniques: Practice deep breathing, meditation, or yoga to help manage stress.
Therapy: Consider seeking cognitive-behavioral therapy (CBT) to help manage anxiety.
Lifestyle: Maintain a regular sleep schedule, eat a balanced diet, and exercise regularly.

Cardiac Arrhythmia

Monitor Symptoms: Keep track of your symptoms, including when they occur and any potential triggers.
Follow-Up: Schedule a follow-up appointment with your doctor for further cardiac evaluation.
Lifestyle: Avoid nicotine and other stimulants that can exacerbate arrhythmias.

Vestibular Disorders

Vestibular Exercises: Perform vestibular rehabilitation exercises as recommended by a healthcare provider.
Avoid Triggers: Identify and avoid movements or positions that trigger your symptoms.
Consult a Specialist: Consider seeing an ENT specialist or neurologist for further evaluation.

What you should look out for

Given the complexity and severity of your symptoms, it's important to seek medical care. Reasons to seek care more urgently include:

Severe or Worsening Symptoms: If your dizziness or lightheadedness becomes severe or worsens.
Chest Pain or Discomfort: Any new or worsening chest pain should be evaluated immediately.
Fainting: If you experience fainting or near-fainting episodes.
Neurological Symptoms: New or worsening numbness, tingling, or difficulty with balance and coordination.

Remember, while I can provide information and suggestions, it's crucial to consult with a healthcare professional for a formal diagnosis and appropriate treatment. You can also use MDandMe to journal your symptoms, track progress, get insights, and share longitudinal medical notes with your provider.