Persons who have had frequent and severe attacks of swooning, without any manifest cause, die suddenly.
HIPPOCRATES (?460–377 BCE), APHORISMS, 11, 41
When patients present with the complaint of a ‘funny turn’ it is usually possible to determine that they have one of the more recognisable presenting problems, such as fainting, ‘blackouts’, lightheadedness, weakness, palpitations, vertigo or migraine. However, there are patients who do present with confusing problems that warrant the label of ‘funny turn’. The most common problem with funny turns is that of misdiagnosis, so a proper and adequate history-taking is of great importance.
It is important to remember that seemingly ‘funny turns’ may be the subjective interpretation of cultural and linguistic communication barriers, especially in an emotional and frustrated patient.1 Various causes of faints, fits and funny turns are presented in TABLE 54.1. A useful simple classification is to consider them as:
++ Table Graphic Jump Location Table 54.1Faints, fits and funny turns: checklist of causes (excluding tonic–clonic seizure and stroke) ||Download (.pdf) Table 54.1 Faints, fits and funny turns: checklist of causes (excluding tonic–clonic seizure and stroke)
Conversion reactions (hysteria)
Transient ischaemic attacks
Complex partial seizure (temporal lobe epilepsy)
Tonic, clonic or atonic seizures
Primary absence seizure
Migraine variants or equivalents, e.g. acute confusional migraine
Familial periodic paralysis
long QT syndrome
Alcohol and other substance abuse
Carotid sinus sensitivity
Key facts and checkpoints
The commonest cause of ‘funny turns’ presenting in general practice is lightheadedness, often related to psychogenic factors such as anxiety, panic and hyperventilation.2 Patients usually call this ‘dizziness’.
Absence attacks occur with minor forms of epilepsy and with partial seizures such as complex partial seizures.
The psychomotor attack of complex partial seizure presents as a diagnostic difficulty. The most commonly misdiagnosed seizure disorder is that of complex partial seizures or variants of generalised tonic–clonic seizures (tonic or clonic or atonic).
The diagnosis of epilepsy is made on the history (or video electroencephalogram/EEG), rather than on the standard EEG, although a sleep-deprived EEG is more effective.
The triad—angina + dyspnoea + blackout or lightheadedness—indicates aortic stenosis.
Severe cervical spondylosis can cause vertebrobasilar ischaemia by causing pressure on the vertebral arteries that pass through the intervertebral foramina, especially with head turning or looking up.
A diagnostic approach
A summary of the diagnostic strategy model is presented in TABLE 54.2.