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The clinical history is of paramount importance in unravelling the problem. A reliable eye-witness account of the ‘turn’ is invaluable, as is the setting or circumstances in which the ‘episode’ occurred.
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It is essential at first to determine exactly what the patient means by ‘funny turn’. In the process of questioning it is appropriate to evaluate the mental state and personal and social factors of the patient. It may be appropriate to confront the patient about feelings of depression, anxiety or detachment from reality.
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It is important to break up the history into three components. First is the lead-up to the episode; second is an adequate description of what took place during the episode; third are the events that took place after the episode.
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Apart from the events, note the patient’s feelings, symptoms, circumstances and provocative factors. Search for possible secondary gain.
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A sudden onset may be due to cardiovascular causes, especially arrhythmias, which may include the more common supraventricular tachycardias in addition to the less common but more dramatic arrhythmias that may cause unconsciousness. Other causes of a sudden onset include the various epilepsies, vasovagal attacks and TIAs.
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Precipitating factors2
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Enquire about precipitating factors such as emotion, stress, pain, heat, fright, exertion, suddenly standing up, coughing, head movement or hypersomnolence:
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emotion and stress suggest hyperventilation
fright, pain → vasovagal attack
standing up → postural hypotension
exertion → aortic stenosis
head movement → cervical spondylosis with vertebrobasilar insufficiency
hypersomnolence → narcolepsy
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Certain associated symptoms give an indication of the underlying disorder:
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breathing problems and hyperventilation suggest an anxiety state
tingling in extremities or tightening of the hand → anxiety/hyperventilation
visual problems → migraine or TIA
fear or panic → anxiety or complex partial seizure
hallucinations (taste/smell/visual) → complex partial seizure
speech problems → TIA or anxiety
sweating, hunger feelings → hypoglycaemia
related to food → migraine
first thing in morning → consider ‘hangover’
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This requires careful analysis and includes alcohol intake and illicit drugs such as marijuana, cocaine and amphetamines. Prescribed drugs that can cause lightheadedness or unconsciousness are listed in TABLE 54.3 and those causing seizures in TABLE 54.4.
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Sudden cessation of certain drugs such as phenothiazines can also be responsible for ‘funny turns’.
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The past history may give an indication of the cause of the ‘turn’. Such conditions include hypertension, migraine, epilepsy, rheumatic heart disease, diabetes, atherosclerosis (e.g. angina, vascular claudication), alcohol or other substance abuse and psychiatric disorders.
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If the diagnosis is elusive it may help to get the patient to keep a diary of circumstances in which events take place, keeping in mind the importance of the time period prior, during and post episode.
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Important focal points of the physical examination include:
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evaluation of the mental state, especially for anxiety
looking for evidence of anaemia, alcohol abuse and infection
cerebrovascular examination: carotid arteries, ocular fundi, bruits
cardiovascular examination: pulses, BP, heart (the BP should be taken lying, sitting and standing)
the cervical spine
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Subject the patient to a number of manoeuvres to try to induce various sensations in order to identify the one that affects them. These should include sudden assumption of the erect posture from a squat, spinning the patient and then a sudden stop, head positioning with either ear down (see FIG. 46.3, CHAPTER 46), Valsalva manoeuvre, and hyperventilation for 60 seconds. Children can spin a showbag ‘windmill’ while hyperventilating (blowing). Ask ‘Which one mimics your complaint?’
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Depending on the clinical findings, investigations can be selected from the following tests:
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full blood count: ? anaemia ? polycythaemia
blood sugar: ? diabetes ? hypoglycaemia
metabolic studies: urea and electrolytes, calcium, magnesium
ECG: ? ischaemia ? arrhythmia
24-hour ambulatory cardiac (Holter) monitor: ? arrhythmia
radiology/imaging and neuroimaging:
EEG or video EEG; include those recorded with sleep deprivation, hyperventilation or photic stimulation
positron emission tomography (PET) or single photon emission computerised tomography (SPECT) may show localised brain dysfunction when others are negative