“I go dizzy and my heart races every time I stand up — school think I’m making it up”

Disabling postural symptoms in a teenager must be taken SERIOUSLY and worked up — defaulting to "it’s just anxiety/attention-seeking" (as the school here has) is both a clinical error and damaging; anxiety may coexist or contribute but is not a substitute for assessment. Recognise the POSTURAL TACHYCARDIA SYNDROME (PoTS) picture: orthostatic symptoms (dizziness, palpitations, brain fog, fatigue, near-syncope) on standing, with a sustained heart-rate rise of ≥30 bpm (≥40 bpm at ages 12–19) within 10 minutes of standing and WITHOUT a significant postural BP drop (Heart Rhythm Society 2015, international) — commoner in young women, often post-viral or with hypermobility, and genuinely disabling. Work the differential (postural hypotension, vasovagal syncope, anaemia/iron deficiency, thyroid disease, and the must-not-miss arrhythmia/inherited cardiac disease — screen the NICE CG109 red flags (exertional syncope, FAMILY HISTORY of sudden cardiac death under 40 or inherited cardiac condition, abnormal ECG, heart failure, unexplained breathlessness, murmur) plus lying syncope and palpitations with collapse — plus hypoglycaemia, medication and anxiety). Assess with an ACTIVE STANDING test arranged face to face (lying/standing HR and BP at intervals — not possible over video) and basic tests (FBC, ferritin, U&E, TFTs, glucose, ECG), referring to cardiology for red flags. PoTS management is NON-DRUG-FIRST (HRS 2015, international) — increased fluid (the 2–3 L/day figure is for adults; agree a teenager’s amount with the specialist) and salt, gradual position change, physical counter-manoeuvres, compression garments, graded reconditioning exercise, sleep and trigger avoidance — with specialist-initiated medication if needed. Crucially, BELIEVE and engage the teenager directly, VALIDATE the real school/functional and psychological impact, and ADVOCATE concretely (a letter and reasonable adjustments — water, seating, rest, exam flexibility — with the school’s duty under the Children and Families Act 2014 s100, usually an individual healthcare plan), offering her time alone and confidentiality at 16 (GMC 0–18 years), addressing any coexisting anxiety supportively without using it to dismiss her, and refer appropriately.