Medical Matters: Nothing humorous about diagnosing a patient’s ‘funny turn’

One of the strengths of general practice and primary care is the ability to make sense of the vaguest of symptoms. Patients tell you they feel “tired all the time” or a “bit of discomfort” and with little more to go on, you begin to unravel the diagnostic challenge.

The phrase “funny turn” is typical of these vague presentations; it often involves dizziness, with the person feeling quite unsteady to the point of needing to lean against a wall or some furniture. And the potential diagnoses vary widely, including neurological and cardiovascular conditions as well as metabolic disorders and psychological problems.

It can be quite a challenge to unravel these in a 15-minute initial consultation.

Dizziness

The nature of the dizziness needs to be clarified. Is the person describing vertigo: “Is the room spinning, or are you spinning?” Is the dizziness more of a light-headedness, in which case feeling faint may be a more accurate description? Or does the patient feel unsteady on their feet, or off balance?

Other important questions include the presence or absence of palpitations, whether there was jerking of the limbs and whether there was either a loss or altered sense of consciousness.

Weakness on either side of the body, or speech disturbance, could indicate a stroke, while recent changes in mood or anxiety might point to a psychological cause.

The timing and onset of the funny turn may offer some diagnostic clues, as could any precipitating factors.

Did it come on after standing up suddenly or after changing position in bed? The former suggests low blood pressure and the latter possibly an indicator of a benign form of vertigo.

Some funny turns represent a potential medical emergency and one of the key tasks for the doctor is to identify these by means of a thorough physical examination.

Even where there is no objective evidence of a stroke, the person’s story may suggest the now resolved turn was a transient ischaemic attack (TIA) or “mini-stroke”. This can be a useful warning of a more severe stroke to come in some days or weeks.

To assess the level of risk, an ABCD2 score is calculated. Points are given for age (over 60) and if the person’s blood pressure is greater than 140/90.

The C stands for clinical features with point to unilateral weakness or speech disturbance while the first D refers to the duration of the transient attack (2 points if it lasted longer than 60 minutes). The second D refers to the presence or absence of diabetes.

High risk

A score of 4 or greater indicates a high risk of future stroke and suggests a need for early specialist assessment, preferably within a week.

Blood tests may help rule out metabolic causes for the turn such as anaemia or low blood sugar, while an ECG reading will pick up any disturbance of the heart’s rhythm known to cause light-headedness.

Diagnosing seizures in the context of a funny turn can be quite a challenge. Syncope is the medical term for fainting or passing out. It is defined as a transient loss of consciousness and postural tone, due to low blood flow to the brain.

Characterised by rapid onset, short duration and spontaneous recovery, the classical teaching is that in syncopal collapse, no motor activity occurs in the muscles of the body.

However, in one study of healthy volunteers with artificially induced syncope some 90 per cent experienced muscle jerking, leading to a presumptive but incorrect diagnosis of epilepsy.

It frequently emerges that a side effect of medication is to blame. A recent change in the dose of a drug to lower blood pressure is an obvious cause.

A new drug prescribed in recent weeks may also be the culprit.

I have yet to meet a patient complaining of a “worrying turn”. Given that some of the causes are far from funny, doesn’t the commonly used nomenclature seem odd?

mhouston@irishtimes.com muirishouston.com