I first saw 21-year-old Dizzy when she was brought to the student health centre by a friend after having fainted in class. She had recovered by the time of her assessment and the examination was unremarkable. Dizzy reported being prone to fainting. I gave her some lifestyle advice, asked her to follow up for a complete physical and sent her for a CBC, B12, Ferritin, TSH, FBS and electrolytes.
The following week Dizzy’s complete exam was again normal and the only finding on her lab work was a mildly decreased B12. She informed me further that this problem had been going on for almost two years; she had had frequent ER visits, and lab, Holter, CT, CXR, EEG, PFT and echo were all normal. In addition, she had been assessed by an endocrinologist and a neurologist who both reported no significant pathology in their fields of expertise. Her family history included maternal breast cancer and a cousin with low B12. She denied any abnormal stress, slept well, ate well and exercised regularly.
Two weeks later Dizzy was again brought to the clinic having fainted in class (and fit in between appointments). She now stated she was fainting about four times a week, with no particular triggers or pattern and always recovered well. In addition she constantly felt weak, light-headed, “foggy.” occasionally short of breath and had frequent shaking of her right arm. Examination was again unremarkable. I also received a letter from one of her professors advocating for Dizzy and requesting an MRI.
Do you know what’s wrong with Dizzy?
I saw Dizzy the following week for a half-hour appointment, this time with her aunt, who reminded her that this was the third anniversary of her mother’s death and wondered if this was a factor in her symptoms. Dizzy again denied this being “all in her head” and stated she was seeing a counsellor to deal with her grief. Further questioning elicited symptoms of anxiety. She scored 34 on the Beck Anxiety Inventory (indicating a severe anxiety disorder).
At great length, I educated Dizzy about anxiety; that it was not “all in her head” but a recognizable medical condition which explained all her symptoms. She agreed to try an SSRI (escitalopram). On follow-up three weeks later, her symptoms had almost completely resolved; there was no further fainting or shaking and she was functioning better.
This case highlights the importance of what’s always taught in medical school: 90% of diagnoses are achieved through history alone. It also points to the importance of continuity of care with one physician. ER visits and specialist appointments focused on eliminating a serious cause for her condition, but didn’t help diagnose or treat her. Well-meaning friends only heightened her anxiety. This case also serves as a reminder of the sometimes unusual ways in which anxiety disorders can manifest.
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