Fits, faints and funny turns

Question 1

Probability diagnosis

Answer 1

Anxiety related/hyperventilation

Vasovagal syncope

Postural hypotension

Breath-holding attacks (children)

Question 2

Serious disorders not to be missed

Answer 2

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

Question 3

Pitfalls (often missed)

Answer 3

1. Atypical migraine
2. Cardiac arrhythmias/long QT syndrome
3. Simple partial seizures
4. Complex partial seizures
5. Atypical tonic–clonic seizures
6. Drugs/alcohol/marijuana/illicit drugs
7. Electrolyte disturbances (e.g. hypokalaemia)
8. Hypoxia
9. Sleep disorders
10. Transient global amnesia
11. Micturition/cough syncope
12. Rarities:

• atrial myxoma
• Stokes–Adams attacks

Question 4

Masquerades checklist

Answer 4

Depression

Diabetes (hypoglycaemia, ketoacidosis)

Drugs

Anaemia

Endocrine (Addison disease, hypothyroidism)

Spinal dysfunction (cervical spondylosis)

Question 5

Is the patient trying to tell me something?

Answer 5

Highly likely.

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

Question 6

Key history

Answer 6

Fundamental to diagnosis.

A reliable eyewitness account of the ‘turn’ is invaluable.

Determine what pt means by ‘funny turn’.

Evaluate the mental, personal and social factors.

Assess three components:

1. lead-up to the episode
2. description of the episode
3. post-episode events.

Consider onset, precipitation factors and associated symptoms

Drug history and past hx, esp substance abuse.

Question 7

Key examination

Answer 7

Evaluate;

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

Look for evidence of;

• anaemia
• alcohol abuse
• infection

Question 8

Key investigations

Answer 8

• 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).

Question 9

Diagnostic tips

Answer 9

The commonest cause of ‘funny turns’ is lightheadedness, often related to psychogenic factors such as;

• anxiety
• panic
• hyperventilation.

Pts 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.