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Probability diagnosis

Anxiety related/hyperventilation

Vasovagal syncope

Postural hypotension

Breath-holding attacks (children)

Serious disorders not to be missed


  • dysrhythmias, e.g. SVT

  • acute coronary syndrome/silent AMI

  • aortic stenosis

  • postural orthostatic tachycardia syndrome (POTS)


  • TIAs


  • space-occupying lesions


  • infective endocarditis


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)


Sleep disorders

Transient global amnesia

Micturition/cough syncope


  • atrial myxoma

  • Stokes–Adams attacks

Masquerades checklist


Diabetes (hypoglycaemia, ketoacidosis)



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


  • FBE


  • 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.

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