CDC Case Challenge: A Woman With Fatigue, Palpitations, and Headache

Jennifer R. Chevinsky, MD, MPH; Sallyann M. Coleman King, MD, MSc; Robert A. Bonacci, MD, MPH; Brendan R. Jackson, MD, MPH; Alyson B. Goodman, MD, MPH; Jessica Rogers-Brown, PhD, MPH; Valentine Wanga, PhD, MS; Jennifer R. Cope, MD, MPH; Stacey Konkle, PhD, MPH; Miriam Nji, MD, MPH; Melissa Briggs-Hagen, MD, MPH; Elizabeth R. Unger, PhD, MD; Brook Belay, MD, MPH; Sharon Saydah, PhD


September 02, 2021

Editorial Collaboration

Medscape &

Many patients with post-COVID conditions may experience triggering or worsening of symptoms when moving to and/or maintaining an upright posture. This is known as orthostatic intolerance (OI). Symptoms of OI can include frequent dizziness and light-headedness, palpitations, and feeling faint. Because patients may not recognize that they have orthostatic intolerance, it can be helpful to ask additional questions to elicit this information:

  • How do you feel when you have been standing still for more than 1-2 minutes?

  • What happens after you get up rapidly from sitting for a long time?

  • How long can you stand before feeling ill? For example,

    • Can you do the dishes?

    • Can you stand in a line for a bus?

    • Are you able to shop in the grocery store or be at the mall for more than a few minutes?

    • Can you take a hot shower or hot bath without feeling tired and light-headed?

Direct measures of OI can be obtained with a relatively simple standing test, such as the NASA lean test. A formal tilt table test may also be considered. These tests are not required for diagnosis but will identify patients with an abnormal response to standing, increased heart rate (also known as POTS or postural orthostatic tachycardia syndrome), and/or low or high blood pressure (known as orthostatic hypo- or hypertension).

Symptom inventories and assessment tools can help evaluate and monitor the status of post-COVID conditions. Functional testing can also be helpful to quantitatively document clinical status over time. For more information about assessment and testing in patients experiencing possible post-COVID conditions, see the assessment and testing section of the CDC interim guidance.

The patient's NASA lean test was positive, exhibiting OI.