CASE REPORT :

VERTIGO
Supervised by : dr. Linda Suryakusuma, Sp.S, MA

Magdalena Sunaryo 201806010074

Sagita Pratiwi Sugiyono 201806010078
Patient’s Identity
Name : Mr. O

Age : 53 Years Old

Occupation :-

Education : Senior High School

Address : Bandengan

Date of Examination : September 24th, 2019

History Taking
Chief Complaint : dizziness since 1 week before came to the Clinic

Additional Complaint : uncontrolled movement of left arm

History of Present Illness : Mr. O, 53 years old came to the clinic with
complaint of dizziness since 1 week ago. He felt like everything is turning
around (spinning). He first felt the dizziness since June 2019 when he got
stroke, but not too disturbing. Since 1 week ago, the dizziness is getting worse,
and 2 days ago he felt even worse. He was doing his daily activity (walking)
when he felt it, and getting better when he lay down. Patient claimed that the
dizziness he felt never completely disappeared, it is just that the intensity
changes.
The patient also complained of uncontrolled movement of the left arm
since he had a stroke.

Sometimes patient claim to be able to do the same thing over and over
(ex: taking key on the table, then put it back, and take it again)

Patient’s wife said that the patient is often difficult to regulate what he
wants to do (ex: he wanted to go to the bedroom, but turn the other way)

Other complaints such as nausea, vomiting, fever, flu, cough, buzzing ears
or pain denied
History of Past Illness :
- Ischemic Stroke, June 2019 (weakness on the left superior and
inferior extremities) à not inpatient.
- Hypertension, June 2019
- Dyslipidemia
- Diabetes Mellitus denied

Family History : Father and Mother have

uncontrolled hypertension.
Medication History :
- Aspilet 1x80mg
- Amlodipine 1x5mg
- Simvastatin 1x5mg

Lifestyle : history of consuming alcohol, drug usage

and smoking denied
 Physical Examination
● General : slightly ill ● BP : 150/100mmHg

● Consciousness : compos ● HR : 92x/min, regular

mentis, E4M6V5 ● Temp : 36.6oC

● Cooperation : cooperative ● RR : 20x/minute

● Body Type : asthenicus ● SaO2 : 99%

PHYSICAL EXAMINATION
Blood Vessel [Pulsation/Thrill/Bruit] (right/left)

● Common Carotid Artery : (+)(-)(-)/(+)(-)(-)

● Temporal Artery : (+)(-)(-)/(+)(-)(-)
● Subclavian Artery : (+)(-)(-)/(+)(-)(-)
● Dorsalis Pedis Artery : (+)(-)(-)/(+)(-)(-)
HEAD
● Calvaria : Hematoma (-), Crepitation (-), Deformity (-)
● Face : Symmetrical
● Eyes : Anemic conjunctival (-/-), icteric scleral (-/-)
● Nose : Deformity(-), Secrete (-/-), Blood(-/-)
● Ears : Deformity(-), Secrete (-/-), Blood(-/-)
NECK
● JVP : 5+2 cmH2O
● Carotid : pulse rate is bounding, full, strong on
palpation
● Thyroid gland : no enlargement, in the midline
● Trachea : in the midline
● Lymphatic gland : no enlargement / mass on palpation
THORAX
Lung : Symmetrical expansion, Resonant, Vesicular
(+/+), Rhonchi (-/-), Wheezing (-/-)

Heart : No cardiac impulse visible, Regular, Gallop (-),

Murmur (-)

Abdomen : Flat, Hepatomegaly (-), Splenomegali (-),

Tympanic, No Tenderness.
External Genitalia : not examined

Extremities : warm, CRT <2s, edema (-)

Muscle and joint : rigidity (-), spasticity (-)

NEUROLOGICAL EXAMINATION
MENINGEAL SIGN RAISED ICP SIGN

● Neck Stiffness :- ● Headache :-

● Kernig :- ● Blurred vision :-
● Brudzinski I :- ● Bradycardia :-
● Brudzinski II :- ● Papilledema :-
CRANIAL NERVE EXAMINATION
CN. I (right/left) : normal

CN. II (right/left)

Visual acuity : normal

Colour vision : normal

Visual field : normal

Funduscopy : red reflex (+/+), papilledema (-)

CN. III-IV-VI (right/left)
● Eyeball position : orthophoria
● Pupil
● Ptosis : -/-
○ Shape : round
● Eks/enophthalmus : -/- ○ Size : 3mm/3mm
● Diplopia : -/- ○ Isochoric: isochoric
● Eyeball movement ● Light reflex
○ Lateral (+/+) ○ Direct : +/+
○ Medial (+/+) ○ Indirect : +/+
○ Superior (+/+) ○ Accommodation Reflex: +
○ Inferior (+/+)
CN. V (right/left)

● Motoric
○ Mouth opening : normal
○ Moving jaw : normal
○ Bite/chew : normal
● Sensoric [touch,heat,pain]
○ Ophthalmic : normal
○ Maxillary : normal
○ Mandibular : normal
● Corneal Reflex : +/+
● Masseter Reflex :-
CN. VII (right/left)
● Expression : normal
● Raising eyebrows : normal
● Closing eyes : normal
● Puffing out cheeks : normal
● Revealing teeth : normal
● Tasting in ⅔ anterior : normal
CN. VIII (right/left)

● Vestibular Nerve
○ Nystagmus : (-/-)
○ Vertigo :+
○ Romberg Test : can’t be evaluated
● Cochlear Nerve
○ Tinnitus : (-/-)
○ Fingers : (+/+)
○ Schwabach : (+/+)
○ Rinne : (+/+)
○ Weber : no lateralisation
CN. IX-X (right/left)
● Voice (aphonia/disphonia/normal) : normal
● Swallowing : normal
● Coughing : normal
● Pharyngeal Reflex : normal
● Pharyngeal Arch
○ Resting : symmetrical
○ Phonation : symmetrical
CN. XI (right/left)
● Sternocleidomastoid muscle : +/+
● Trapezius muscle : +/+
CN. XII (right/left)

● Dysarthria :-
● Tongue position
○ Inside the mouth : middle
○ Sticking out : middle
● Tongue movement
○ Right :+
○ Left :+
● Fasciculation :-
● Atrophy :-
MOTORIC
Strength (right/left) ● Upper leg
○ Anteflexion : 5/5
● Upper arm ○ Retroflexion : 5/5
○ Anteflexion : 5/5 ○ Abduction : 5/5
○ Retroflexion : 5/5 ○ Adduction : 5/5
○ Abduction : 5/5 ● Lower leg
○ Adduction : 5/5 ○ Flexion : 5/5
● Lower arm ○ Extension : 5/5
○ Flexion : 5/5 ● Feet
○ Extension : 5/5 ○ Plantar flexion : 5/5
○ Dorso flexion : 5/5
PHYSIOLOGICAL REFLEX
● Biceps : ++/++
● Triceps : ++/++
● Patellar : ++/++
● Achilles : ++/++
● Abdominal skin :+
● Abdominal muscle :+
PATHOLOGICAL REFLEX
● Hoffman Tromner : -/-
● Babinski : -/-
● Chaddock :-/-
● Oppenheim : -/-
● Gordon : -/-
● Schaeffer : -/-
● Clonus : -/-
TONE
● Upper extremities
○ Rest : normotonic
○ Passive movement : normotonic
● Lower extremities
○ Rest : normotonic
○ Passive movement : normotonic
● Trophic : normotrophic
COORDINATION AND CEREBELLAR FUNCTION
Static
● Sitting : no abnormalities
● Standing : no abnormalities
● Intention tremor : -/+
● Dysdiadochokinesia : -/+
● Rebound Phenomenon : -/+
Dynamic
● Finger-nose : +/-
● Finger-finger :-
● Heel-knee : +/-
SENSORIC
(touch/temperature/pain)

● Upper extremities : +/+/+

● Lower extremities : +/+/+
● Body : +/+/+
● Feeling of movement : +/+/+
● Feeling of vibration : +/+/+
● Two points discrimination : +/+/+
● Attitude and direction : +/+/+
AUTONOMIC:
Micturition (+), Defecation (+), Sweating (+)

HIGHER CORTICAL FUNCTION:

- Motor aphasia :-
- Sensory aphasia :-
- Memory and counting :-
- Apraxia :-

REGRESSION:
- Glabellar reflex :-
- Sucking reflex :-
- Grasp reflex :-
RESUME
Mr. O, 53 years old came to Atma Jaya Polyclinic with complaint of dizziness
since 1 week ago, which worsen 2 days before he came. The dizziness felt like
“spinning”, and never really disappeared since the first time he felt it (June
2019, stroke). He was walking when he felt it worsen.

Patient also complaint uncontrolled movement of the left arm, often doing
repetitive action.

Other complaints, such as nausea, vomiting, fever, tinnitus, denied.

Patient had history of ischemic stroke, hypertension, and dyslipidemia since

June 2019, with daily medication: aspilet 1x80mg, amlodipine 1x5mg,
simvastatin 1x5mg.
In the physical examination, BP 150/100 mmHg, HR, RR, Temperature,
and SpO2 in the normal range. There no abnormalities on general
examination. In neurological examination, Vertigo +, Nystagmus -/-. In
examining coordination and cerebellar function, we find dysmetria +,
rebound phenomenon -/+, intention tremor -/+, heel knee +/-,
dysdiadochokinesia -/+.
 APPROACH CONSIDERATION
- Neuroimaging : Head MRI or CT Scan (rule out infarction,
hemorrhage, tumors)
- Laboratory test : CBC, Electrolytes, Glucose, Lipid profile
HEAD MRI (September 24th, 2019)
- Old lacunar infarct in left corona radiata, right centrum semiovale, both
sides of putamen, left globus pallidus and both sides of thalamus.
- Small lesion affecting right body of corpus callosum (can be old micro
hemorrhage)
- Mild cerebral atrophy
DIAGNOSIS
● Clinical : Vertigo, Intention tremor -/+, Dysdiadochokinesia -/+,
Heel to Knee +/-, Finger-finger -, Finger to Nose +/- (Dysmetria +)
● Etiology : Vascular
● Topical : Cerebellum Sinistra
● Pathology : Ischemia
TREATMENT
● Salicylic acid 1x80 mg
● Amlodipine 1x5mg
● Simvastatin 1x5mg
● Betahistine 2x24mg
● Dimenhydrinate 3x50 mg
PROGNOSIS
● Quo ad vitam : bonam
● Quo ad functionam : dubia ad bonam
● Quo ad sanationam : dubia ad malam
LITERATURE REVIEW
Dizziness
Vestibular System
VERTIGO
Abnormal sensation of motion which can occur in
the absence of motion or vice versa (subjective
vertigo) which may result from the disease of the
inner ear or disturbances of vestibular centers or
pathways in the CNS.
Classification
Vestibular :

Central Vertigo

Peripheral Vertigo

Non vestibular Vertigo

Central Vestibular Vertigo
- Vestibular Migraine
- TIA Vertebrobasiler
- Cerebellopontine angle and posterior fossa meningioma
Peripheral Vestibular Vertigo
- BPPV (Benign Paroxsysmal Positional Vertigo)
- Meniere’s disease
- Vestibular Neuritis
- Labirynthitis
- Vestibular Schwannoma
- Perilymphatic Fistula
Non Vestibular Vertigo
- Orthostatic Hypotension
- Hypoglycemia
- Head Trauma
- Ocular Vertigo
- Psychogenic
- etc
Vestibular Migraine
- Spontaneous episodic vertigo (10%)
- Photophobia (+), phonophobia(+)
- Aura (+)

Ergotamin (3x 1-2 mg), Tricyclic antidepressant

(Amitriptyline (25 mg), beta blockers
(propanolol 3x40 mg)
Vertebrobasilar TIA
- Vertebrobasilar = Posterior circulation
- Supply to : brainstem, cerebellum, and
occipitalis cortex.

- Vertigo
- Visual field defects, nystagmus ( vertical)
- Auditory phenomena
- Facial numbness, paresthesia
- Dysphagia, dysarthria, hoarseness
- Syncope

Hemodynamic insufficiency & embolism

Anti thrombotic ( Aspirin, clopidogrel)

BPPV ( Benign Paroxyxmal Positional Vertigo)
- Recurrent Vertigo
- Provoked by changes in the position of head
- No hearing loss , no tinnitus

Accumulation of crystal composed of calcium

carbonat (otoconia) within the labirin in the
posterior semicircular canal
Head movement —> debris drift + movement of
endolymph —> induce vertigo

Canalith repositioning manuver, anti vertigo

 Meniere’s Disease
- 2 or more episodic vertigo (persist >20 min)
- Nystagmus ( horizontal / rotatory)
- Tinnitus, aural fullness, sensorineural
progressive & fluctuating hearing loss
Etiology: autoimmune,genetic ( familial), allergy,
infeksi, endocrine, head trauma, vascular
Endolymph hidrops—> fluid accumulation,
swelling & distortion—> ruptur & release
endolymph fluid—> mixed with perilymph
Low salt intake (1,5 g/hr), triamterene &
hydrochlorothiazid), anti vertigo
Neuritis Vestibular
- Sudden Vertigo, persist for several days
- Severe nausea
- Horizontal Nystagmus (contralateral to the
lesion)
- Imbalance (veer toward the side of lession)
- Neurologic deficit (-), hearing loss(-)

Distension of perilymph compartment—>

thinning & atrophy of Reissner membrane and
sakular wall—> ruptur & release endolymph fluid
Anti vertigo (AH, benzodiazepin)
Methyl prednisolon (100 mg)
Anti viral (Acyclovir 3x400 mg)
Antibiotic (Amoxicillin 3x 500 mg)
Clinical Manifestation
- Dizziness
- Nausea vomiting
- Nystagmus
- Additional complaint: Balance disorder,
hearing loss/ tinnitus, headache, motoric
disorder, etc)
History Taking
- Dizziness → characteristics “swinging”
- Provoked by changes of head or body position, fatigue, stress
- Onset: acute, paroxysmal, chronic
- With or without hearing disorders (hearing loss, tinnitus)
- With or without limbs paresthesia
- Medication history
- History of past illness: anemia, CVD, hypertension, hypotension, etc
Dizziness Algorithm
Physical Examination
- Otoscopy (impaction)
- Tuning fork test (hearing loss)
- Nystagmus
- Gait test (propioceptive)
- HINTS test
Otoscopy - impaction
- Vesicle (Ramsay Hunt syndrome)
- Mass (Cholesteatoma, etc)
Tuning fork test - hearing loss
- Rinne test
- Weber test
- Schwabach test
Gait test- proprioseptif
- Romberg test
- Babinski Weil test
- Unteberger test
- Barany pointing test
Dix Hallpike Maneuver
Differential Diagnosis
Further Work-up
- Laboratory test : CBC, Urinalysis
- Radiology : Head Xray (stenvers view), Head CT scan
without contrast
- Neurophysiology : EEG
Non Pharmacological Treatment
- Epley Maneuver
- Brandt Daroff Maneuver
- Lempert Roll Maneuver
- Supine Roll Maneuver
Epley Maneuver - canalith repositioning
Brandt Daroff
Lempert roll manuver -horizontal canal
Supine roll maneuver (Pagnini-McClure maneuver) -
horizontal canal
Pharmacological Treatment
- CCB : Flunarizine 3x 5-10 mg
- AH : Dimenhydrinate 3x50 mg, diphenhydramine
1x 10-20 mg
- Histaminik : Betahistine mesylate 3x8 mg atau betahistine
dihydrochloride 2x24 mg
- Benzodiazepine (diazepam) : 3x2-5 mg
REFERENCES
- Thompson TL, Amedee R. Treatment of Vertigo: A Review of Common
Peripheral and Central Vestibular Disorders.Oschner. 2009;9(1):20-6
- Kelompok studi Vertigo PERDOSSI.Pedoman Tatalaksana Vertigo. Jakarta.
2017
- John C. Current Diagnosis and Treatment Neurology. New York. Lange.
2012; 2
- Lui F, Foris LA, Willner K, Tadi P. Central Vertigo. In: StatPearls. Treasure
Island (FL): StatPearls Publishing; 2019
- Dizziness: Approach to Evaluation and Management - American Family
Physician