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Probability diagnosis

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Anxiety related/hyperventilation

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Vasovagal syncope

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Postural hypotension

++

Breath-holding attacks (children)

++

Serious disorders not to be missed

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Cardiovascular:

++

  • dysrhythmias, e.g. SVT

  • acute coronary syndrome/silent AMI

  • aortic stenosis

  • postural orthostatic tachycardia syndrome (POTS)

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Cerebrovascular:

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  • TIAs

++

Neoplasia:

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  • space-occupying lesions

++

Infections:

++

  • infective endocarditis

++

Hypoglycaemia

++

Pitfalls (often missed)

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Atypical migraine

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Cardiac arrhythmias/long QT syndrome

++

Simple partial seizures

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Complex partial seizures

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Atypical tonic--clonic seizures

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Drugs/alcohol/marijuana/illicit drugs

++

Electrolyte disturbances (e.g. hypokalaemia)

++

Hypoxia

++

Sleep disorders

++

Transient global amnesia

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Micturition/cough syncope

++

Rarities:

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  • atrial myxoma

  • Stokes–Adams attacks

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Masquerades checklist

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Depression

++

Diabetes (hypoglycaemia, ketoacidosis)

++

Drugs

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Anaemia

++

Endocrine (Addison disease, hypothyroidism)

++

Spinal dysfunction (cervical spondylosis)

++

Is the patient trying to tell me something?

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

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Key history

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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.

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Key examination

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

  • Look for evidence of anaemia, alcohol abuse and infection

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Key investigations

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Consider:

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  • 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).

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Diagnostic tips

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  • 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.

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