Case Report SENIOR CLINICAL CLERKSHIP Presented byFebrian Nur HellyNurmega Kurnia SaputriAdvisorDr. H. A. Rachman Toyo, SpS(K)

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Case ReportIdentificationName: Mrs. IAge: 33 years oldGender: femaleMarital Status: marriedReligion: MoslemAddress: stay in townAdmission Date : November 7th 2010

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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 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*

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.

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PHYSICAL EXAMINATIONSense : compos mentis (GCS 15: E4M6V5)Blood pressure : 110 / 80 mmHgPulse : 80x/minuteRespiratory rate : 20x/minuteTemperature : 36,6o CNutrition : sufficient

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Neurological stateNervi cranialesVestibular nerve: Nystagmus (-),Vertigo(+).

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Neurological state*

Sensory function: No abnormalityVegetative function : No abnormality Limbic function: No abnormalityAbnormal Movement: (-) Gait & Stability: (-)Meningeal Irritation: (-)

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Additional ExaminationBloodTrigliseride : 65 mg/dl (65)LDl : 159 mg/dl (

Planning for cervical X-ray in Anteroposterior, lateral and oblique positions. *

DIAGNOSIS Clinical Diagnosis Benign Positional Vertigo + Hypercholesterolemia Topical Diagnosis LabyrinthEtiological Diagnosis Idiopathic

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TreatmentNon medicationGive information about this disease and how to treat this disease by physical exercise.MedicationIVFD RL gtt XX/minBetahistine mesylate 3 x 6 mgDimenhydrinat 3 x 50mg ampSimvastatin 1 x 20 mg tabletVitamin B1, B6, B12 100mcg 1 x 1 tabletConsult to ENT departmentPlan to have cervical x-ray

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PROGNOSIS Quo ad vitam : bonamQuo ad functionam : bonam

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From Anamnesisdizziness with the sensation of spinning.complaint happened and worsen when She changed the positionlasted a few seconds to a few minutes and intermittentThere was Nausea and vomitingpatient felt the dizziness more severe and increasing of nausea and vomiting*

From Physical ExaminationNystagmus (-)Dysmetria (-)Romberg Test (-)Dix-hallpike (-)

From additional examinationHypercholesterolemia

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From all above, we concluded that this patient suffered fromBenign Positional Vertigo + Hypercholesterolemia*

Differential Diagnosis for Topical Diagnosis:Central lessionPeripheral lession*

Case analysis-con't-1Central Lession

Dizziness with sens of spinning, gradually & last days to weeks (permanent)Independent of changing position & head moving.Mild attackNystagmus (+), vertical, fatigue (-), latency (-), habit (-). With brainstem dis symp:diplopia, disartria, disphagia, disphonia. With cerebellum dis symp: coordination dis, difficulty & trembling in doing skillfull movement.

Symptomps of the patiens were:Sudden onset, last a few seconds to a few minutes and intermittent (come and go).Depend on changing position and moving the head.Severe attackNystagmus (-)Brainstem disorder (-)Symptoms of cerebellum dis (-)So, the possibility of central lesion can be rejected..*

Case analysis-con't-2Peripheral LessionDizziness with vertigo, vomiting develop suddenly, lasted a few days to a few weeksPatient usually feel relieved but not purely free from the symptompsDepend on changing position and the head.Severe attackNystagmus (+) with horizontal direction and fatigue(+), latency (+), habituation (+).

Symptomps of the patiens were:Sudden onset, last a few seconds to a few minutes and intermittent (come and go), with vomitingDepend on changing position and moving the head. Cposition moving the head worsen the dizzinessSevere attackNystagmus (-)So, the possibility of peripheral lesion can not be rejected..*

Case analysis-con't-3

Differensial Diagnosis for Etiology:1. Medication2. Ear infection3. Head injury4. Menier disease5. Idiophatic

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Case analysis-con't-4MedicationHistory 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..*

Case analysis-con't-5Ear 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..*

Case analysis-con't-6Head InjuryHistory 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..*

Case analysis-con't-7Menierre's DiseaseEpisodic 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 lossVertigo attack is severe and will be recovered after takesome medication.So, the possibility of menierre's disease can be rejected..*

For the treatmentNon medicationGive information about this disease and how to treat this disease by physical exercise.MedicationIVFD RL gtt XX/minDimenhydrinat 3 x 50mg ampBetahistine mesylate 3 x 6 mgSimvastatin 1 x 20 mg tabletVitamin B1, B6, B12 100mcg 1 x 1 tabletPlan to servical X-rayConsult to ENT department

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