Fits, faints and funny turns

Probability diagnosis

Anxiety related/hyperventilation

Vasovagal syncope

Postural hypotension

Breath-holding attacks (children)

Serious disorders not to be missed

Cardiovascular:

• dysrhythmias, e.g. SVT

• acute coronary syndrome/silent AMI

• aortic stenosis

• postural orthostatic tachycardia syndrome (POTS)

Cerebrovascular:

• TIAs

Neoplasia:

• space-occupying lesions

Infections:

• infective endocarditis

Hypoglycaemia

Pitfalls (often missed)

Atypical migraine

Cardiac arrhythmias/long QT syndrome

Simple partial seizures

Complex partial seizures

Atypical tonic--clonic seizures

Drugs/alcohol/marijuana/illicit drugs

Electrolyte disturbances (e.g. hypokalaemia)

Hypoxia

Sleep disorders

Transient global amnesia

Micturition/cough syncope

Rarities:

• atrial myxoma

• Stokes–Adams attacks

Masquerades checklist

Depression

Diabetes (hypoglycaemia, ketoacidosis)

Drugs

Anaemia

Endocrine (Addison disease, hypothyroidism)

Spinal dysfunction (cervical spondylosis)

Is the patient trying to tell me something?

Highly likely. Psychogenic-pseudo-seizures and ‘communication’ disorders quite significant.

Key history

Fundamental to diagnosis. A reliable eyewitness account of the ‘turn’ is invaluable. Determine what the patient means by ‘funny turn’. Evaluate the mental, personal and social factors. Assess three components: lead-up to the episode, description of the episode and post-episode events. Consider onset, precipitation factors and associated symptoms; also drug history and past history, especially substance abuse.

Key examination

• Evaluate mental state, cerebrovascular/cardiovascular status, cervical spine

• Look for evidence of anaemia, alcohol abuse and infection

Key investigations

Consider:

• FBE

• ESR/CRP

• blood sugar

• U&E

• ECG

• 24-hour ambulatory cardiac monitor

• EEG or video EEG

• selected radiology (e.g. carotid duplex Doppler scan).

Diagnostic tips

• The commonest cause of ‘funny turns’ is lightheadedness, often related to psychogenic factors such as anxiety, panic and hyperventilation. Patients usually call this dizziness.

• Migraine is a great mimic and can cause confusion in diagnosis.

• The more bizarre the description of a ‘funny turn’ the more likely a functional problem is the cause.