THEME: Fits, faints and funny turns Fits, faints and funny turns A general diagnostic approach

BACKGROUND The patient presenting with a fit, faint or ‘funny turn’ can present a diagnostic dilemma for the general practitioner. John Murtagh OBJECTIVE This article aims to provide an overview of the diagnostic approach to these ‘episodes’. DISCUSSION The key to diagnosis is to elicit a clear history focussing on the lead-up to the episode, a description of what took place and the events that took place after the episode. The patient’s feelings, symptoms, circumstances and provocative factors give vital information.

he relatively common problem presentation of a diagnosis. I favour a diagnostic model that consid- Tfainting attack, ‘funny turn’ or seizure usually ers probabilities and serious disorders that the represents an emergency in the community with sig- general practitioner cannot afford to miss, and nificant emotional sequelae to the patient, their other aspects according to the diagnostic strategy friends and family and witnesses. It is important to model presented in Table 2.2 realise that the simple syncopal attack, once so History John Murtagh, common in outdoor school assemblies, is not readily AM, MD, BSc, BEd, recognised by members of the new generation. The clinical history is of paramount importance in FRACGP, When patients present with the complaint of a unravelling the problem. A reliable eye witness DipObstRCOG, is Adjunct Professor ‘funny turn’ it is usually possible to determine that account of the ‘turn’ is invaluable, as is the setting of General Practice, they have one of the more recognisable presenting or circumstances in which the ‘episode’ occurred. Monash University problems, such as fainting, ‘blackouts’, lighthead- It is essential at first to determine exactly what Professorial Fellow of General Practice, edness, weakness, palpitations, vertigo or migraine. the patient means by ‘funny turn’. In the process of University of However, there are patients who do present with questioning, it is appropriate to evaluate the Melbourne and confusing problems that warrant the label of mental state and personal and social factors of the Adjunct Professor, ‘funny turn’. The commonest cause of funny turns patient. It may be appropriate to confront the Graduate School of Integrative Medicine, presenting in general practice is lightheadedness, patient about feelings of depression, anxiety or Swinburne University, often related to psychogenic factors such as detachment from reality. It is important to break Victoria. anxiety, panic and hyperventilation.1 Patients up the history into three components: usually call this ‘dizziness’. The issue of most • the lead-up to the episode concern with funny turns is that of misdiagnosis, so • an adequate description of what took place a proper and adequate history taking is of great during the episode, and importance. • the events that took place after the episode. Various causes of fits, faints and funny turns Apart from the events, note the patient’s feelings, are presented in Table 1. A useful, simple classifi- symptoms, circumstances and provocative factors. cation is to consider them as: Search for possible secondary gain, either con- • syncope scious or unconscious. • seizures • sleep disorders, eg. sleep apnoea, catoplexy, or Onset • labyrinthine. A sudden onset may be due to cardiovascular causes, especially arrhythmias, which may include The diagnostic approach the more common supraventricular tachycardias in An approach to diagnosis should ideally follow the addition to the less common, but more dramatic, traditional method of history, examination and arrhythmias that may cause unconsciousness.

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Other causes of a sudden onset include the various Table 2. Diagnostic strategy model: seizure disorders, vasovagal attacks and transient fits, faints and funny turns ischaemic attacks (TIAs). Probability diagnosis Precipitating factors Anxiety related/hyperventilation Enquire about precipitating factors such as Vasovagal syncope emotion, stress, pain, heat, fright, exertion, sud- Postural hypotension denly standing up, coughing, head movement or Breath holding attacks (children) hypersomnolence: Serious disorders not to be missed • emotion and stress suggest hyperventilation Cardiovascular • fright, pain suggests vasovagal attack • arrhythmias • aortic stenosis Table 1. Selected causes of fits, faints Cerebrovascular and funny turns (excludes tonic-clonic • TIAs seizure and CVAs) Neoplasia • space occupying lesions Psychogenic (communication problems) Severe infections Conversion reactions (hysteria) • infective endocarditis Culture/language conflicts Hypoglycaemia Fugue states Pitfalls (often missed) Hyperventilation Atypical migraine Malingering Cardiac arrhythmias Personality disorders Simple partial seizures Phobia/anxiety states Complex partial seizures Psychoses/severe depression Atypical tonic-clonic seizures Other conditions Drugs/alcohol/marijuana Transient ischaemic attacks Electrolyte disturbances (eg. hypokalaemia) Complex partial seizure (temporal lobe epilepsy) Sleep disorders Tonic, clonic or atonic seizures Rarities Primary absence seizure • atrial myxoma Migraine variants or equivalents • transient global amnesia Cardiovascular disorders Seven masquerades checklist • arrhythmias Depression 4 • postural hypotension Diabetes 4 • aortic stenosis – hypoglycaemia Vertigo Drugs 4 Drug reaction Anaemia 4 Alcohol and other substance abuse Thyroid disorder - Hypoglycaemia Spinal dysfunction 4 Anaemia – cervical spondylosis Amnesic episodes UTI Metabolic/electrolyte disturbances Is this patient trying to tell me something? Vasovagal/syncope Highly likely Carotid sinus sensitivity Psychogenic and communication disorders quite Cervical spondylosis common in this setting Sleep disorders • sleep apnoea • narcolepsy/cataplexy Autonomic failure

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• standing up suggests postural hypotension Past history • exertion suggests aortic stenosis The patient’s past history may give an indication of • head movement suggests cervical spondylosis the cause of the ‘turn’. Such conditions include with vertebrobasilar insufficiency hypertension, migraine, epilepsy, rheumatic heart • hypersomnolence suggests narcolepsy. disease, atherosclerosis (eg. angina), vascular clau- dication, alcohol or other substance abuse, and Associated symptoms psychiatric disorders. A history of childhood con- Certain associated symptoms give an indication of vulsions may predispose to the development of the underlying disorder: hippocampal sclerosis and temporal lobe epilepsy. • breathing problems and hyperventilation suggest an anxiety state Diary of events • tingling in extremities or tightening of the hand If the diagnosis is elusive it may help to get the suggests anxiety/hyperventilation patient to keep a diary of circumstances in which • visual problems suggests migraine or TIA events take place, keeping in mind the importance • fear or panic suggests anxiety or complex of the time period before, during and postepisode. partial seizure • hallucinations (taste/smell/visual) suggests The examination complex partial seizure Important focal points of the physical examination • speech problems suggests TIA or anxiety include: • sweating, hunger feelings suggests hypoglycaemia • evaluation of the mental state, especially for • related to food suggests migraine anxiety • first thing in morning, consider ‘hangover’. • looking for evidence of anaemia, alcohol abuse and infection Drug history • cerebrovascular examination: carotid arteries, This requires careful analysis and includes alcohol ocular fundi, bruits intake and illicit drug use such as marijuana, • cardiovascular examination: pulses, blood pres- cocaine and amphetamines. Prescribed drugs that sure, heart (BP should be taken lying, sitting can cause lightheadedness or unconsciousness are and standing) listed in Table 3. Sudden cessation of certain drugs • the cervical spine. such as phenothiazides and antidepressants can also be responsible for funny turns. Table 3. Examples of drugs that may cause lightheadedness or blackouts

Alcohol Peripheral vasodilators • angiotensin II blockers • glyceryl trinitrate • hydralazine • prazosin Antiepileptics Antihypertensives Barbiturates Benzodiazepines Phenothiazines Phenoxybenzamine SSRI antidepressants Tricyclic antidepressants OTC anticholinergic compounds

Figure 1. Dix-Hallpike manoeuvre

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• electroencephalogram (EEG) or video EEG; EEGs include those recorded with sleep depri- vation, hyperventilation or photic stimulation • positron emission tomography (PET) or single photon emission computerised tomography (SPECT) may show localised brain dysfunction when others are negative (available via special- ist referral only).

Conclusion The patient presenting with the problem of a faint, fit or funny turn can present a true diagnostic dilemma for the busy GP and occasionally a diag- nosis may not be made. On the other hand, the cause may be quite simple or readily determined. A key to diagnosis is to elicit a clear history of the event or events and this is where an eye witness Figure 2. Valsalva manoeuvre account can be crucial. Adverse drug reactions constitute an ever increasing cause of these prob- Various manoeuvres lems especially in the elderly in whom the Subject the patient to a number of manoeuvres to possibility of a vascular disorder particularly an try to induce various sensations in order to identify arrhythmia or a cerebrovascular event should the one that affects them. These should include: always be kept in mind. sudden assumption of the erect posture from a squat, spinning the patient and then a sudden stop, SUMMARY OF head positioning with either ear down – Dix- IMPORTANT POINTS Hallpike manoeuvre (Figure 1), Valsalva manoeuvre (Figure 2), and hyperventilation for 60 • Adequate clinical history taking is essential. seconds. Children can spin a toy ‘windmill’ while • Note the events, patient’s feelings, symptoms, hyperventilating (blowing). Ask the patient: circumstances and provocative factors. ‘Which one mimics your complaint?’ • Subject the patient to a number of Investigations manoeuvres to try to induce various sensations. Depending on the clinical findings and working • Investigations may include full blood count, X- diagnosis, the most appropriate investigations can ray, CT scan, or EEG. be selected from the following tests: • full blood count: ? anaemia ? polycythaemia • blood sugar: ? diabetes ? hypoglycaemia • urea and electrolytes Conflict of interest: none declared. • electrocardiogram (ECG): ? ischaemia ? arrhythmia References • 24 hour ambulatory cardiac (Holter) monitor: 1. Sandier G, Fly J. Early clinical diagnoses. Lancaster: MTP Press, 1986:411–430. ? arrhythmia 2. Murtagh J. Common problems: a safe diagnostic • radiology/imaging strategy. Aust Fam Physician 1990; 19:733–742. – cervical X-ray AFP – chest X-ray – carotid duplex Doppler scan: ? carotid artery stenosis REPRINT REQUESTS – computerised tomography (CT) scan – magnetic resonance imaging (MRI) scan John Murtagh (available via specialist referral only) Email: [email protected]

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