Fits, Faints And Funny Turns
Fits, faints, and funny turns is a clinical umbrella term for transient episodes of altered consciousness or awareness, encompassing seizures, syncope, and other paroxysmal events that require systematic differentiation to identify their underlying neurological, cardiac, or metabolic cause.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Vasovagal syncope | Situational trigger (pain, emotion, prolonged standing), prodrome of nausea/sweating, brief LOC, quick recovery [1][2] | 「你暈之前有冇出汗、作嘔、頭暈？嗰陣係咪企咗好耐？」 |
| Orthostatic hypotension | LOC/presyncope on standing; elderly on antihypertensives [2] | 「你起身嗰陣有冇暈？」→ Lying-to-standing BP drop ≥ 20/10 mmHg | |
| Serious Not To Miss | Cardiac arrhythmia (VT/VF, complete heart block) | Sudden LOC without warning, during exertion or supine, palpitations before, FHx sudden death [1][2] | 「暈之前有冇覺得心跳好快或者突然停？」→ ECG: prolonged QT, Brugada pattern, heart block |
| Structural heart disease (aortic stenosis, HCM) | Exertional syncope, ejection systolic murmur [2][5] | 「做運動嗰陣有冇暈？」→ Auscultation: ESM at aortic area / LLSE | |
| Epilepsy | Aura, tonic-clonic movements, tongue biting (lateral), incontinence, post-ictal confusion > 5 min [1] | 「有冇人見到你成個人抽筋？醒返之後有冇好迷糊好耐？」 | |
| Subarachnoid haemorrhage | Thunderclap headache + syncope, neck stiffness | 「有冇突然間好劇烈嘅頭痛？好似俾人打咗一棍咁？」 | |
| Pulmonary embolism | Pleuritic chest pain, SOB, leg swelling, recent immobilisation | 「有冇單邊腳腫？最近有冇坐長途機或者做完手術？」 | |
| Pitfalls | Hypoglycaemia | DM on insulin/SU, hunger + sweating + tremor before LOC, relieved by eating [6] | 「你有冇糖尿？暈之前有冇肚餓、出汗、手震？食完嘢有冇好返？」 |
| Carotid sinus syndrome | Elderly, triggered by shaving/head turning, asystole > 3s on CSM [2] | 「暈嗰陣你有冇剃鬚或者撥頭？」 | |
| BPPV/Vertigo misdiagnosed as syncope | Room spinning, positional, no true LOC | 「你覺得個世界有冇轉？定係淨係覺得暈暈哋？」 | |
| Masquerades | Drug-induced (antihypertensives, QT-prolonging drugs) | New medication or dose change temporally related [2] | 「你最近有冇轉藥或者加藥？」 |
| Anaemia | Pallor, fatigue, exertional presyncope | 「你有冇面青、好攰、或者氣喘？」 | |
| Depression / anxiety / panic disorder | Hyperventilation, perioral tingling, no true LOC, situational | 「你最近心情點？有冇成日好緊張？」 | |
| Trying to Tell Me Something? | Psychogenic non-epileptic seizures (PNES) | Prolonged variable movements, eyes closed during event, no post-ictal confusion, secondary gain | 「你最近有冇咩壓力大嘅事？」 |
| Fear of serious illness / hidden agenda | E.g. friend recently had stroke; wants brain scan; worried about driving | 「你最擔心係咩？有冇咩特別想我幫你排除？」 |
GC Slide High Yield [5]: Syncope/presyncope cardiovascular causes include arrhythmias, postural hypotension, aortic stenosis, HCM, atrial myxoma. Other causes: simple faints, epilepsy, anxiety.
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日想同你傾下你嘅問題，大約傾六分鐘，方唔方便呀？」 | Scores interpersonal marks: greeting, introduction, time frame, permission |
| 0:30–2:00 | Chief complaint + HPI: Open Q → focused Qs | 「可唔可以話我知發生咗咩事？」→「嗰陣時你有冇失去知覺？」→「之前有冇任何先兆？」 | Must clarify: was it LOC (faint/fit) or dizziness without LOC? This is the key branch point |
| 2:00–3:00 | Discriminating features: syncope vs seizure vs other | 「你跌低嗰陣有冇人見到？有冇抽筋、咬脷、失禁？」→「醒返之後有冇好攰或者好亂？」 | Witness account is gold. Tongue-biting + prolonged confusion = seizure; brief LOC + quick recovery = syncope [1] |
| 3:00–4:00 | Red flags, PMHx, DHx, FHx, Social Hx | 「你有冇心臟病、糖尿、腦癇症嘅病史？」→「屋企人有冇猝死或者心臟病？」→「你平時食咩藥？」 | Family history of sudden death → cardiac syncope/inherited arrhythmia; drugs causing hypotension/QT prolongation [2] |
| 4:00–4:45 | ICE: Ideas, Concerns, Expectations | 「你自己覺得可能係咩原因？」→「你最擔心嘅係咩？」→「你今日嚟最想我幫你做啲咩？」 | High marks for ICE. Uncover hidden agenda: e.g. worried about brain tumour, wants to keep driving licence, fear of epilepsy diagnosis |
| 4:45–5:15 | Functional impact + psychosocial screen | 「呢件事有冇影響到你返工、揸車、或者日常生活？」→「你最近壓力大唔大？瞓得好唔好？」 | Social/functional impact is Case Report Q5b material |
| 5:15–5:45 | Summarise back to patient | 「等我總結返：你喺…嗰陣暈低咗，之後…係咪咁？」 | Shows active listening; scores summary marks |
| 5:45–6:00 | Safety-net + close | 「如果你再暈倒、抽筋、或者胸口痛，一定要即刻去急症室。我哋會安排返進一步檢查，好唔好？」 | Safe closure with red-flag safety-net advice |
Hidden agenda tips: The patient may not present with "I fainted." They may say "funny turns" (陣陣暈) or "I felt strange." Always ask 「你嚟睇醫生最主要嘅原因係咩？」 — the RFC may be fear of epilepsy, worry about driving safety, pressure from family, or an upcoming job medical.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Nature of episode | Did you actually lose consciousness? | 「你有冇真係失去知覺，完全唔知發生咩事？」 | Distinguishes true LOC (syncope/seizure) from dizziness/vertigo/presyncope [1] | LOC → syncope or seizure; no LOC → vertigo, presyncope, anxiety |
| Witness account | Did anyone see what happened? Any jerking, tongue-biting, incontinence? | 「有冇人見到？有冇成個人抽筋、咬到條脷、或者瀨咗？」 | Witness account is the single most valuable discriminator [1] | Tonic-clonic movements + tongue biting + incontinence → seizure |
| Prodrome | What did you feel just before? | 「暈之前有冇咩感覺？例如頭暈、出汗、心跳、作嘔？」 | Nausea/sweating/lightheadedness → vasovagal; aura (déjà vu, odd smell) → seizure [1] | Palpitations before → arrhythmia; no warning → cardiac syncope |
| Duration of LOC | How long were you out? | 「你大約暈咗幾耐？幾秒定幾分鐘？」 | Syncope: LOC typically < 1 min; Seizure: LOC typically > 1 min [1] | Prolonged LOC + slow recovery → seizure or cardiac |
| Post-ictal features | After waking, were you confused, sleepy, or had headache? | 「醒返嗰陣你有冇好迷糊、好攰、或者頭痛？」 | Prolonged confusion post-event = seizure; quick recovery = syncope [1] | Post-ictal confusion + Todd's paresis → focal seizure |
| Trigger/situation | What were you doing? Standing long? Hot environment? Pain? | 「嗰陣你做緊咩？企咗好耐？好熱？有冇受驚或者痛？」 | Situational trigger → vasovagal syncope [2] | On exertion → cardiac (AS, HCM, arrhythmia); after standing → orthostatic |
| Position | Were you standing, sitting, or lying? | 「你嗰陣係企緊、坐緊、定瞓緊？」 | Supine LOC essentially rules out vasovagal → think cardiac or seizure | Lying flat → cardiac arrhythmia or seizure |
| Palpitations | Did you feel your heart racing or skipping? | 「有冇覺得心跳好快、唔規則、或者漏拍？」 | Preceding palpitations → arrhythmic syncope | SVT, VT, AF with fast rate |
| Chest pain/SOB | Any chest pain or breathlessness? | 「有冇胸口痛或者氣喘？」 | Chest pain + syncope = ACS or aortic dissection; SOB = PE [3] | ACS, PE, aortic dissection — all emergencies |
| Exertional syncope | Does it happen during exercise? | 「做運動嗰陣有冇暈過？」 | Exertional syncope = red flag for structural heart disease (AS, HCM) or arrhythmia [2] | Aortic stenosis, HCM, LQTS, ARVD |
| Frequency/recurrence | How many times? First time? | 「呢個情況發生咗幾多次？第一次定以前都試過？」 | Recurrent → needs workup; single vasovagal may be benign | Recurrent unexplained → Holter, echo, tilt-table |
| Medications | What medications are you taking? | 「你平時食咩藥？有冇食血壓藥、心臟藥、鎮靜劑？」 | Antihypertensives → orthostatic; QT-prolonging drugs → arrhythmia [2] | Drugs masquerade: beta-blockers, diuretics, antipsychotics, macrolides |
| PMHx | Any heart disease, epilepsy, diabetes, stroke? | 「你有冇心臟病、腦癇症、糖尿病、中風嘅病史？」 | Known cardiac disease + syncope = high-risk; DM → hypoglycaemia | Cardiac syncope 30% 1-year mortality [1] |
| Family Hx | Any sudden death, heart disease, or epilepsy in family < 40yo? | 「屋企人有冇人試過猝死、心臟病、或者腦癇症？特別係後生嗰啲？」 | FHx of sudden cardiac death < 40 → inherited arrhythmia (LQTS, Brugada, HCM) [2][4] | LQTS, Brugada syndrome, HCM |
| Social: driving | Do you drive? | 「你有冇揸車？」 | Driving restriction is a key safety issue after syncope/seizure | Must counsel on driving fitness |
| Social: occupation | What is your job? Work at heights? | 「你做咩工作？有冇喺高處做嘢？」 | Fall risk from LOC at work; occupational safety | Construction, machinery operators |
| Alcohol/drugs | Do you drink alcohol? Any recreational drugs? | 「你飲唔飲酒？有冇用其他藥物？」 | Alcohol withdrawal seizures; cocaine → arrhythmia | Withdrawal seizures, drug-induced QT prolongation |
| Psych screen | Any stress, anxiety, low mood? | 「最近有冇壓力大、緊張、或者情緒低落？」 | Panic attacks mimic syncope; hyperventilation → presyncope; PNES | Psychogenic non-epileptic seizures (PNES), panic disorder |
| Red flag: headache | Any sudden severe headache? | 「有冇突然間好劇烈嘅頭痛？」 | SAH can present with syncope + thunderclap headache | Subarachnoid haemorrhage |
Case Report Form Answer Builder
- CC: e.g. "Episode(s) of loss of consciousness" / "Blackout" / "Funny turn" — use the patient's words
- HPI high-yield points to capture:
- Number of episodes, most recent episode date
- Circumstances: position, activity, trigger
- Prodrome: aura vs presyncope symptoms
- Witness account: movements, colour, duration
- Duration of LOC
- Post-event: confusion, tongue biting, incontinence, injury
- Associated symptoms: palpitations, chest pain, SOB, headache
- Functional impact: driving, work, ADLs
Likely RFC examples:
- "Worried about why I fainted"
- "Family/employer told me to see a doctor"
- "Concerned about epilepsy / brain tumour"
- "Need medical clearance for driving"
- "Fear of sudden death — relative had heart attack"
How to phrase: Pick the ONE reason that drove the patient to come today. It is not the symptom itself but the motivation. Write: "Patient is concerned about the cause of recurrent blackouts and worried about safety at work."
| Component | Likely Examples | Exact Wording to Write |
|---|---|---|
| Ideas | "I think I might have epilepsy" / "Maybe low blood pressure" | "Patient thinks the episode may be due to epilepsy/low blood sugar" |
| Concerns | "Worried it could be a brain tumour / heart problem" / "Afraid of losing driving licence" | "Patient is worried about having a serious brain or heart condition; also concerned about impact on driving" |
| Expectations | "Wants a brain scan / blood tests" / "Wants referral to specialist" | "Patient expects investigation (e.g. brain scan/ECG) and specialist referral to identify the cause" |
- In FM primary care with a young/middle-aged patient: Vasovagal syncope (most common cause of syncope, ~60%) [1]
- Minimum supporting evidence: situational trigger + prodrome of nausea/sweating/lightheadedness + brief LOC (< 1 min) + rapid full recovery without confusion
- If history suggests seizure features: Epilepsy (new-onset seizure)
- Choose based on the stem: if clear trigger + quick recovery → vasovagal; if witnessed tonic-clonic + post-ictal confusion → epilepsy
| DDx | One Key Discriminator |
|---|---|
| Cardiac arrhythmia | Sudden LOC without warning, during exertion or supine, ± palpitations, FHx sudden death; abnormal ECG |
| Orthostatic hypotension | LOC/presyncope immediately on standing; on antihypertensives; postural BP drop ≥ 20/10 |
| Epilepsy (or vasovagal if main Dx is epilepsy) | Aura, witnessed tonic-clonic, lateral tongue biting, post-ictal confusion > 5 min |
(Adjust based on stem: always include one "serious not to miss" cardiac cause)
| Domain | Problem |
|---|---|
| Biological | Risk of injury from uncontrolled LOC episodes (e.g. head trauma, fractures); need to investigate for cardiac or neurological cause |
| Psychological | Anxiety and fear about having a serious condition (e.g. brain tumour, epilepsy); fear of recurrence; possible low mood |
| Social/Functional | Impact on driving fitness and occupational safety; restricted independence; social embarrassment; financial impact if unable to work |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Vasovagal syncope | No reliable physical sign in FM station (exam is usually normal) | Lying-to-standing BP + HR: reproduction of presyncope symptoms without significant postural drop confirms vasovagal tendency; formal diagnosis via head-up tilt test | Normal examination supports benign vasovagal by excluding structural/cardiac causes |
| Orthostatic hypotension | Postural blood pressure drop ≥ 20 mmHg SBP or ≥ 10 mmHg DBP within 3 min of standing [2] | Measure BP lying (after 5 min rest) then standing at 1 and 3 min | Diagnostic criterion for orthostatic hypotension |
| Cardiac arrhythmia | Irregular pulse / bradycardia / tachycardia on pulse palpation | Radial pulse for 15 seconds × 4; note rate and regularity | Irregular or abnormally slow/fast pulse suggests arrhythmia; ECG needed for confirmation |
| Aortic stenosis | Ejection systolic murmur (ESM) at aortic area, radiating to carotids [5] | Auscultate with diaphragm at right 2nd intercostal space; patient sitting up, leaning forward, end-expiration | ESM + slow-rising pulse + narrow pulse pressure = haemodynamically significant AS causing exertional syncope |
| HCM | ESM at left lower sternal edge, louder with Valsalva [4] | Auscultate at LLSE; ask patient to perform Valsalva (reduces preload → increases LVOT obstruction → louder murmur) | Dynamic LVOT obstruction murmur characteristic of HCM |
| Epilepsy | Lateral tongue bite mark [1] | Inspect tongue for lateral bite wounds or scars | Lateral tongue biting is highly specific for generalised tonic-clonic seizure (vs tip-of-tongue biting in syncope) |
Top Traps That Lose Marks
- Failing to distinguish syncope from seizure from vertigo from presyncope — always ask: "Did you actually lose consciousness?" and "Did the room spin?" These are different presentations requiring different workups.
- Not asking for witness account — the witness history is the single most valuable piece of information. Ask: 「有冇人見到嗰陣發生咩事？」
- Forgetting to ask about exertional syncope — this is a red flag for structural cardiac disease (AS, HCM) and inherited arrhythmias; it MUST be asked in every case.
- Missing drug history — antihypertensives, QT-prolonging drugs (macrolides, antipsychotics, antiemetics), insulin/sulfonylureas causing hypoglycaemia are common masquerades.
- Not asking FHx of sudden cardiac death — misses LQTS, Brugada, HCM.
- Confusing RFC with CC — the CC is "blackout/funny turn"; the RFC is WHY they came TODAY (e.g. fear of epilepsy, employer requested medical clearance).
- Forgetting to assess functional/social impact — driving, work at heights, living alone = key biopsychosocial marks.
Must-not-miss red flags → urgent referral / A&E:
- Syncope during exertion
- Syncope with chest pain or severe headache
- Syncope with new neurological deficit
- FHx sudden cardiac death < 40 years old
- Known structural heart disease + syncope
- ECG showing prolonged QT, Brugada pattern, heart block, or VT
Shortest safe management/safety-net line: 「如果你再暈倒、抽筋、胸口痛、或者突然好劇烈頭痛，一定要即刻去急症室。唔好一個人揸車住，等我哋檢查結果出返先。」
GC Slide Key Point [5]: Syncope differential must include both cardiovascular causes (arrhythmias, postural hypotension, aortic stenosis, HCM, atrial myxoma) and non-cardiovascular causes (simple faints, epilepsy, anxiety).
GC Slide [7]: Seizure and loss of consciousness — must differentiate delirium, encephalopathy, epilepsy, coma; provoked vs unprovoked seizures. Provoked seizures include drugs, metabolic (hypoGly, hypoCa, hypoNa), CNS infection, acute stroke, head trauma, febrile convulsion.
High Yield Summary
What to ASK: (1) True LOC vs dizziness/vertigo? (2) Witness account — jerking, colour, duration? (3) Prodrome — aura vs presyncope? (4) Post-event confusion duration? (5) Triggers — exertion, standing, situational? (6) Palpitations/chest pain? (7) Drug history including QT-prolonging drugs? (8) FHx sudden death? (9) Driving and occupation? (10) ICE — why today?
What to WRITE: CC in patient's words; HPI with full episode description; RFC = the real reason today (fear/functional need); ICE clearly separated; Most likely Dx with 3 supporting features; 3 DDx each with discriminator; BPS problems covering injury risk, anxiety, driving/work impact; Physical sign = postural BP (orthostatic) or tongue bite (seizure) or murmur (cardiac).
What NOT to MISS: Exertional syncope (cardiac red flag); FHx sudden death < 40; drug-induced causes; lateral tongue bite = seizure not syncope; PNES as a pitfall; driving safety advice.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Ryan Ho Neurology.pdf (Section 4.1.1 Faints and Fits); Ryan Ho Fundamentals.pdf (Section 3.4.4 Faints and Fits); Ryan Ho Cardiology.pdf (Section 2.4 Syncope) [2] Senior notes: Maksim Medicine Notes.pdf (Section 6.8 Syncope); MBBS Final MB (Medicine) (Felix PY Lai).pdf (Syncope section, p317) [3] Senior notes: Block A - Accelerating chest pain_ Acute Coronary Syndromes.pdf; Block A - Leg swelling and chest pain_ deep vein thrombosis; pulmonary embolism.pdf [4] Senior notes: Block A - Inherited Cardiac conditions.pdf (HCM, LQTS, Brugada sections) [5] Lecture slides: CFB (MED05) Cardiovascular (I) Physical Examination (History Taking).pdf (Cardiac Symptoms table, p9) [6] Senior notes: Block A - Endocrine Data Interpretation.pdf (Hypoglycaemia section); Block A - Polyuria and polydipsia_ glucose metabolism; diabetes mellitus; diabetic ketoacidosis.pdf (Hypoglycaemia section) [7] Lecture slides: GC 081. Seizure and loss of consciousness Delirium and encephalopathy; epilepsy; coma and brain death; care of unconscious patients; electrophysiology I.pdf [8] Senior notes: Adrian Lui Pediatrics Notes.pdf (p117, Febrile seizure and Paroxysmal disorders)
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