1. The document describes two cases of peripheral vertigo seen by Dr. Sanjay Maharjan. 2. The first case involves a 51-year-old man experiencing right-sided vertigo, nausea, and vomiting for one week. Examination revealed right-sided benign paroxysmal positional vertigo (BPPV), which was treated successfully with Epley maneuver. 3. The second case involves a 45-year-old man with fever, runny nose, dizziness, and nausea/vomiting for several days. Examination found horizontal nystagmus, and he was diagnosed provisionally with vestibular neuritis. He was admitted and treated with medications, showing improvement after

1. CASE OF PERIPHERAL
VERTIGO
DR. SANJAY MAHARJAN
2ND YR RESIDENT, ENT-HNS,
MTH.

2. CASE I

3. PARTICULARS OF THE PATIENT:
Hosp no. : 7305067
Age: 51yr
Address: fulbari-11, pokhara
Occupation : Shopekeeper
Date of OPD visit: 15-01-2018

4. CHIEF COMPLAINTS :
 Dizziness for 1 week
 Nausea vomitting for 1 week

5. HISTORY OF PRESENT ILLNESS:
• Dizziness:
• Started at night at around 3:00 AM
• True Rotatory sensation
• Intermittent
• Lasts < 1 min
• Aggravated when looking up, looking down
and especially looking to Right
• Relieved while sleeping without moving his
head

6.  Also c/o constant woozy/drunk feeling worse
when looking down
 Nausea and vomitting:
 Associated with dizziness
 Severe episodes of nausea
 Vomitting 3-4 times

7. • No history of:
• LOC or weakness
• Gait deviations
• Pain around neck or difficulty moving
head
• Ear discharge or ear ache
• Aural fullness or Hearing loss
• Tinnitus
• Recent attacks of URTI
• Visual complaints

8.  With these complains pt was taken to a local
hospital where few pints of IVF and antiemetic
was given
 Symptoms did not subside
 Brought to emergency dept of Manipal

9. PAST HISTORY:
 Similar episode but of lesser severity that
relieved after taking some OTC drugs
(undocumented)
 No DM, HTN, TB or COPD
 No history of ear surgery or other major
surgeries

10. DRUG HISTORY:
 No h/o taking any drug regularly
 Not known to be allergic to any drugs

11. PERSONAL HISTORY:
 Appetite: Decreased
 Diet: Mixed
 Bowel and bladder : Regular
 Sleep: Decreased
 Habits – Smoker, non alcoholic

12. FAMILY HISTORY:
 No similar complains
SOCIO-ECONOMIC HISTORY:
 Middle class
 Shopkeeper

13. GENERAL EXAMINATION:
 GC : Anxious, irritable
 BP : 110/80 mmHg
 Temp : 98.5 F
 RR : 22/min
 Pulse : 89b/min

14.  CNS examination :
 GCS : E4V5M6 = 15/15
 B/l Flexor plantar reflex
 Neck rigidity : -ve
 Others grossly intact
 CVS, Chest, P/A :
 Within normal limits

15. LOCAL EXAMINATION:
 Ear:
 Pre-auricular, pinna and post-auricular
region of b/l ear : normal
 EAC : No discharge in b/l ear
 TM : No perforation in b/l ear
 Facial nerve : Intact in both sides

16.  Tuning fork test:
 Rinne’s test : positive B/L
 Weber’s test : Central
 Spontaneous nystagmus : absent
 Pure Tone Audiometry:
 WNL

17.  Subjective tests :
 Fistula test : -ve
 Rhomberg’s test : +ve, falls in R side
 Dix Hallpike maneuver :
 R: +ve severe vertigo & downbeating R
torsional nystagmus, latency 2-3 sec, lasted <
1 min
 L: Normal

18. DIAGNOSIS:
Right BPPV

19. TREATMENT:
 Epley Maneuver for R ear
 Repeated 3 times
 less vertigo / nystagmus during each repeat
 Post-Epley instructions :
 For 48 hrs,
 Avoid sleeping on involved side
 Avoid forceful head movements

20.  Pt discharged with following medications :
 Tab. Prochloperazine 25mg PO TDS 7D
 Tab. Betahistine 16mg PO TDS 2Wks
 Tab. Ondansetron 4mg PO SOS
 Follow up after 1 Wk

21. RE-EVALUATION : 2ND VISIT
 No more vertigo since initial treatment
 Occasional “woozy” feeling when looking
down, but very mild
 Dix Hallpike –ve B/l

22. CASE II

23. PATIENT PARTICULARS
Hosp no. : 7324098
Age: 45yrs
Address: Lekhnath – 14, Tanahu
Occupation : Teacher
Date of admission: 02-02-2018

24. CHIEF COMPLAINTS :
 Fever and runny nose for 5 days
 Dizziness for 2 days
 Nausea vomitting for 2 days

25. HISTORY OF PRESENT
ILLNESS:
 Fever:
 Intermittent
 Max recorded 100F
 Not as/w chills and rigor
 As/w watery nasal discharge & throat pain
 Relieving after taking some OTC drugs
(undocumented) ?gargle ?antihistamine

26.  Dizziness:
 Rotatory sensation
 Sudden onset
 Continuous but gradually decreasing in
severity
 Aggravated on head movement but not on
specific head position
 No relieving factor

27.  Nausea and vomitting:
 Associated with dizziness
 Severe episodes of nausea
 Vomiting multiple episodes

28.  No history of:
 LOC or weakness
 Gait deviations
 Pain around neck or difficulty moving
head
 Aggravation on certain head position
 Ear discharge or ear ache
 Aural fullness or Hearing loss
 Tinnitus

29.  With these complaints brought to emergency room
of Manipal Teaching Hospital

30. PAST HISTORY:
 h/o recurrent attacks of URTI
 k/c/o HTN under medication
 No DM, TB or COPD
 No history of ear surgery or other major
surgeries

31. DRUG HISTORY:
 h/o taking OTC drugs (undocumented) for
fever and throat pain 5 days back
 No other regular use of any drugs
 Not known to be allergic to any drugs

32. GENERAL EXAMINATION:
 GC : Anxious
 BP : 130/80 mmHg
 Temp : 99.5 F
 RR : 20/min
 Pulse : 99b/min
 CNS, CVS, Chest, P/A :
 Grossly intact

33. LOCAL EXAMINATION:
 Ear:
 Pre-auricular, pinna and post-auricular
region of b/l ear : normal
 EAC : No discharge in b/l ear
 TM : No perforation in b/l ear
 Facial nerve : Intact in both sides

34.  Tuning fork test:
 Rinne’s test : Positive B/l
 Weber’s test : Central
 Nystagmus :
 Present spontaneously
 Horizontal, fast beating to left side
 Grade III
 Supressed on looking at the mark

35. PROVISIONAL DIAGNOSIS:
 Vertigo under evaluation, most likely
Vestibular neuritis

36. TREATMENT:
 Pt was admitted in ENT ward with following
medications:
 Tab. Betahistine 16mg PO TDS
 Tab. Cinnarazine 25mg PO TDS
 Inj. Hydrocort 100mg IV TDS
 Inj. Pantoprazole 40mg IV OD
 Inj. Ondansetron 8mg IV TDS
 Inj Phenargan 50mg IM SOS

37. PROGRESS REPORT:
 Pt was symptomatically well following 3 days of
admission
 Nystagmus reduced to Grade I
 PTA done, was normal
 c/o minimal vertigo with sudden movement of
head
 Discharged on 3rd DOA with oral medications