Case Report

SENIOR CLINICAL CLERKSHIP

Presented by
Febrian Nur Helly
Nurmega Kurnia Saputri
Advisor
Dr. H. A. Rachman Toyo, SpS(K)

Case Report
Identification

Name
: Mrs. I
Age
: 33 years old
Gender
: female
Marital Status: married
Religion
: Moslem
Address
: stay in town
Admission Date : November 7th 2010
3

ANAMNESIS (Auto Anamnesis)

The patient was hospitalized in neurology ward
of RSMH Palembang because of the dizziness
with the sensation of spinning.
About 5 days before admitted to the hospital,
the patient felt dizziness accompanied by the
sensation of spinning. The patient described the
complaint happened and worsen when he
changed the position upon rising from a lying or
sitting to a standing position and turned the head
while lying, lasted a few seconds to a few
4
minutes and intermittent.

 The complaint would be subside when she moved

her head to the previous position. She complained
nausea and vomiting. She didnt complain about
tinnitus in the left ear. There was no difficulty in
doing skillful movement and no complain about
difficulty to speak. The patient didnt complain
about double vision and weakness with her eyes.
About 5 hours before admitted, patient felt the
dizziness more severe and increasing of nausea
and vomiting
5

 Patient had no history of Hypertension. No history

of getting fever. No history of secreted the smelly
fluid from the ear. No history of both ringing sound
in the ear and sensation of fullness in the ear that
accompanied by intermittent hearing loss before. No
history of getting head injury. No history of diabetes
mellitus. No history of long-term using
streptomycin, gentamycin, quinine and
antineoplastics agent.
This illness was suffered for the second time.
6

PHYSICAL EXAMINATION

Sense

: compos mentis
(GCS 15: E4M6V5)
Blood pressure
: 110 / 80 mmHg
Pulse
: 80x/minute
Respiratory rate
: 20x/minute
Temperature
: 36,6o C
Nutrition
: sufficient
7

Neurological state
Nervi craniales
Vestibular nerve

: Nystagmus (-),Vertigo(+).

Neurological state

Sensory function : No abnormality

Vegetative function : No abnormality
Limbic function
: No abnormality
Abnormal Movement: (-)
Gait & Stability
: (-)
Meningeal Irritation: (-)
10

Additional Examination

Blood

Trigliseride
: 65 mg/dl (<150)
HDL : 56 mg/dl (>65)
LDl : 159 mg/dl (<130)
Total Cholesterol : 228mg/dl (<200)
Blood glucose : 89 mg/dl (<200)
Ureum : 32 mg/dl (15-39)
Creatinin : 1 mg/dl (0.6-1)
CK-NAK : 126 U/l (70)
CK-MB : 14 U/l (<16)
Natrium : 134 mmol/l (135-155)
Kalium : 3.5 mmol/l (,3.5-5.5)

11

 Planning for cervical X-ray in

Anteroposterior, lateral and oblique
positions.

12

DIAGNOSIS
Clinical Diagnosis
Benign Positional Vertigo + Hypercholesterolemia

Topical Diagnosis
Labyrinth

Etiological Diagnosis
Idiopathic

13

Treatment
Non medication
Give information about this disease and how to treat
this disease by physical exercise.

Medication

IVFD RL gtt XX/min

Betahistine mesylate 3 x 6 mg
Dimenhydrinat 3 x 50mg amp
Simvastatin 1 x 20 mg tablet

Vitamin B1, B6, B12 100mcg 1 x 1 tablet

Consult to ENT department

Plan to have cervical x-ray

14

 PROGNOSIS
Quo ad vitam
: bonam
Quo ad functionam : bonam

15

16

 From Anamnesis
dizziness with the sensation of spinning.
complaint happened and worsen when She
changed the position
lasted a few seconds to a few minutes and
intermittent
There was Nausea and vomiting
patient felt the dizziness more severe and
increasing of nausea and vomiting

17

 From Physical Examination

Nystagmus (-)
Dysmetria (-)
Romberg Test (-)
Dix-hallpike (-)

From additional examination

Hypercholesterolemia
18

 From all above, we concluded that this

patient suffered from
Benign Positional Vertigo +
Hypercholesterolemia

19

Differential Diagnosis for Topical Diagnosis:

Central lession
Peripheral lession

20

Case analysis-con't-1

Central Lession

Dizziness with sens of spinning,

gradually & last days to weeks
(permanent)
Independent of changing position &
head moving.

Symptomps of the patiens were:

Mild attack
Nystagmus (+), vertical, fatigue (-),
latency (-), habit (-).
With brainstem dis symp:diplopia,
disartria, disphagia, disphonia.

Sudden onset, last a few seconds to a

few minutes and intermittent (come and
go).
Depend on changing position and
moving the head.

Severe attack

Nystagmus (-)

Brainstem disorder (-)

Symptoms of cerebellum dis (-)

With cerebellum dis symp:

coordination dis, difficulty & trembling
in doing skillfull movement.

So, the possibility of central lesion can be rejected..21

Case analysis-con't-2

Peripheral Lession
Dizziness with vertigo, vomiting
develop suddenly, lasted a few days to
a few weeks

Symptomps of the patiens were:

Patient usually feel relieved but not

purely free from the symptomps

Depend on changing position and the

head.

Severe attack

Sudden onset, last a few seconds to a

few minutes and intermittent (come and
go), with vomiting
Depend on changing position and
moving the head. Cposition moving the
head worsen the dizziness

Severe attack

Nystagmus (-)

Nystagmus (+) with horizontal

direction and fatigue(+), latency (+),
habituation (+).

So, the possibility of peripheral lesion can not be

rejected..
22

Case analysis-con't-3

Differensial Diagnosis for Etiology:

1. Medication
2. Ear infection
3. Head injury
4. Menier disease
5. Idiophatic

23

Case analysis-con't-4

Medication
History of long-term use
of streptomycin, quinine
and anti neoplastic agent
(+).

Symptomps of the patiens

were:

History of long-term use

of streptomycin, quinine
and anti neoplastic agent
(-).

So, the possibility of medication can be rejected..

24

Case analysis-con't-5

Ear Infection (Otitis Media)

History of secreted the
ear (+).

History of a sensation of
fullness in the ear (+).

Symptomps of the patiens

were:

History of secreted the

ear (-).

History of a sensation of
fullness in the ear (-).

So, the possibility of ear infection can be rejected..

25

Case analysis-con't-6

Head Injury
History of head injury (+)

Sensation of spinning (+)

Symptomps of the patiens

were:

History of head injury (-)

Sensation of spinning (+)

So, the possibility of head injury can be rejected..

26

Case analysis-con't-7

Menierre's Disease

Episodic rotational vertigo, hearing

loss, ringing sound in ear (tinnitus)
and a sensation of fullness in the
affected ear.

Vertigo, tinnitus and sensation of

fullness in ear may come and go with
the fluctuating of hearing loss, be
constant or recovered without
medication.

Symptomps of the patiens

were:
in this patient there is no symptom
of tinnitus and hearing loss

Vertigo attack is severe and will be

recovered after takesome
medication.

So, the possibility of menierre's disease can be rejected..

27

 For the treatment

Non medication
Give information about this disease and how to treat
this disease by physical exercise.

Medication

IVFD RL gtt XX/min

Dimenhydrinat 3 x 50mg amp
Betahistine mesylate 3 x 6 mg
Simvastatin 1 x 20 mg tablet

Vitamin B1, B6, B12 100mcg 1 x 1 tablet

Plan to servical X-ray
Consult to ENT department

28

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