A 60 Y.

O MAN WITH PERIPHERAL VESTIBULAR

VERTIGO
AUDREY DESIREE SUSANTO
030.12.038

Preceptor: dr. Ronny Yoes, Sp S

PATIENTS IDENTITY

Mr. MA Male 60 y.o Married Moslem

Moti Dalam St.

Senior High
Gambir, Central Retired May 9th 2017 15.53.02
JKT School
CHIEF COMPLAINT

Dizziness that became severe approx. 2 days

before the hospital admission date
HISTORY OF PRESENT ILLNESS

Autoanamnesis conducted on May 15 th 2017

The patient had experienced the dizziness for the past 1 month, it is episodic,
and lasted for less than one minute on each attack. He described the dizziness
as spinning, which is exacerbated mostly by head movement, and sometimes
when looking at moving objects and hearing a loud sound (e.g watching
gymnastic or aerobic session). He often felt nauseous but still able to hold
himself from vomiting.
The complaints went severe for the past two days, the dizziness came more
often and lasted longer than before. He couldnt walk on his own, nor
balancing his body while standing. He felt very nauseous and vomited 5x /
day.
HISTORY OF PRESENT ILLNESS

Since then, he became weak and refused to eat. Lying still in bed
without moving helped to alleviate his symptoms.
He denied having complaints such as tinnitus, hearing loss, double
vision, visual field defect, dysarthria, paresthesia, or other
neurologic symptoms favors central vestibular abnormalities.
MEDICAL HISTORY

PAST MEDICAL HISTORY FAMILY MEDICAL HISTORY

Vertigo : He was admitted to the same hospital 1 The occurrence of similar complaints : (-)
year ago. A CT-Scan was conducted with no abnormalities found.
Hypertension : (-)
Hypertension : (-) Diabetes mellitus : (-)
Diabetes mellitus : (-) Lung disease : (-)
Lung disease : (-) Heart disease : (-)
Heart disease : (-) Stroke : (-)
Stroke : (-) Malignancies : (-)
Malignancies : (-)
PHYSICAL EXAMINATION

Consciousness : Compos mentis, GCS 15 (E4M6V5)

Blood pressure : 130/70 mmHg
Pulse : 84x/min, regular
Respiratory rate : 19x/min
Temperature : 36,6 C
GENERAL EXAMINATION

Normocephal
Head Symmetrical

Conjuctival pallor (-), scleral icterus (-)

Eyes Pupil: isocoria 3mm, DLR +/+ IDLR +/+

Cyanosis (-)
Mout
h Dryness (-)
Lymph nodes & thyroid gland not palpable
Neck Neck stiffness (-)
GENERAL EXAMINATION

S1 & SII regular

Heart Gallop (-) murmur (-)

Vesicular breathing sounds +/+

Lungs Rhonci -/- wheezing -/-

Supple, bowel sounds (+)

Abdome
n Organ enlargement (-)

Warm on upper and lower extremities

Extremiti
es Edema (-) on upper and lower extremities
NEUROLOGICAL EXAMINATION

Mening
eal Neck stiffness (-) Speech
signs Brudzinsky I (-)
Motoric aphasia (-)
Sensory aphasia
Brudzinsky II (-)
(-)
Kernig (-)
Dysarthria (-)
Laseque (-)
CRANIAL NERVES EXAMINATION

N.I (Olfactory nerve)

Not performed

N. II (Optic nerve)

Not performed

N. III (Oculomotor nerve)

Strabismus (-)
Nystagmus (-)
Exophtalmos (-)
Pupils : 3 mm / 3 mm; isochoric
Direct light reflex +/+
Indirect light reflex +/+
CRANIAL NERVES EXAMINATION

N. IV (Throchlear nerve)

Eye movement (downward-inside) +/+

Diplopia (-)

N. V (Trigeminal nerve)

Mouth opening: Normal

Chewing and biting: Not examined
Cornea reflex (+/+)
Face sensibility: Normal

N. VI (Abducens nerve)

Eye movement (lateral) +/+

Diplopia (-)
CRANIAL NERVES EXAMINATION

N. VII (Facial nerve)

Furrowing forehead: Symmetrical (+)

Closing eyes: Normal
Puffing cheeks: Normal
Showing teeth: Symmetrical
Taste sensibility: Not examined

N. VIII (Vestibulocochlear nerve)

Swabach, Rinne, Weber: Not examined

N. IX (Glossopharyngeal nerve)

Taste sensibility: Not examined

Pharynx sensibility: Not examined
CRANIAL NERVES EXAMINATION

N. X (Vagus nerve)

Pharyngeal arch: Normal, symmetrical

Speaking: Normal
Swallowing: Not examined
Oculocardiac reflex: Not examined

N. XI (Accessory nerve)

Uplifting shoulders: Symmetrical

Turning head aside: Normal

N. XII (Hypoglossal nerve)

Tongue out: Normal

Articulation: Normal
 Reflexes
MOTORIC AND SENSORIC Physiological
Biceps ++ / ++
Upper and lower extremities Triceps ++ / ++
Sensory Patella ++ / ++
Pain : Normal, Achilles ++ / ++
symmetrical
Temperature : Not examined
Light Touch : Normal,
symmetrical

Motoric Pathologic
Strength : 5555/5555 Babinsky - /-
Trophy : Normal Chaddock - / -
Tone : Normal Schaeffer - / -
NEUROLOGICAL EXAMINATION

Nystagmus : (-)
Sharpened Romberg test: swaying (+) conducted when the
patients dizziness has gone
Heel to knee test : tremor (+) when conducted by left foot
Past pointing test : normal
Disdiadochokinesia : normal
Dix-Hall pike test : not performed
SUMMARY

A 60 y.o male came to the neurologic center of dr. Mintohardjo Navy

Hospital with acute onset of vestibular vertigo, nausea, and
vomiting, all exacerbated with head movement, and sometimes by
looking at moving objects and hearing a loud sound. The symptoms
had been experienced for the past 1 month, and it became severe
for the past two days (there is an increase in the frequency and
duration of the attack). He felt weak, couldnt walk on his own, nor
balancing his body while standing.
He denied having complaints such as tinnitus, hearing loss, double
vision, visual field defect, dysarthria, paresthesia, or other
neurologic symptoms favors central vestibular abnormalities.
SUMMARY

On examination, the patient is conscious (GCS = E4M6V5) with BP

130/70, HR 84x/min, RR 19x/min, and T 36,6C. Cranial nerves
examination was normal, and nystagmus were not found on the patient.
When the symptoms got better, Romberg test was performed and the patient swayed
when doing the sharpened Romberg test. A tremor was observed when the patient
conducted the heel to knee test by his left foot.
LABORATORY EXAMINATIONS
LABORATORY EXAMINATIONS
IMAGING

Non-contrast brain CT-Scan (May 16th 2017)

no abnormalities found
ASSESMENT

Diagnosis
X1 K: Peripheral vestibular vertigo
E : Idiopathic
T : Peripheral vestibular system
P : Displaced otolith
X2 hyponatremia, hypokalemia
TREATMENT

Non pharmacological:
Brandt-Darroff exercises
Pharmalogical
IVFD RL /12 hours
Ranitidine 2 x 50mg (1 amp) i.v
Ondancentrone 3 x 8 mg (1 amp)
Betahistine 2 x 24mg
Flunarizine 1 x 10mg
THANK YOU