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python3 -c " import pdfplumber with pdfplumber.open('/tmp/workspace/attachments/111dc021-2d27-450c-a48a-47e22617b23e/Usha VNG.pdf') as pdf: for i, page in enumerate(pdf.pages): print(f'=== PAGE {i+1} ===') print(page.extract_text()) print() "
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python3 -c " import pdfplumber with pdfplumber.open('/tmp/workspace/attachments/111dc021-2d27-450c-a48a-47e22617b23e/Usha VNG.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): if i >= 12: # pages 13 onwards print(f'=== PAGE {i+1} ===') print(page.extract_text()) print() "
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Detailed Clinical Analysis and Diagnosis
Mrs. Usha Goswamy | 86 years / Female | Max Healthcare, Noida
I. PATIENT SUMMARY
| Parameter | Details |
|---|---|
| Patient | Mrs. Usha Goswamy, 86 yrs 3 mo, Female |
| Referring Physician | Dr. K M Hassan, Neurologist, Max Noida 128 |
| VNG Date | 29 July 2026 (Priority Hearing Care Pvt. Ltd.) |
| Neurology Visit | 07 July 2026 |
II. CLINICAL HISTORY (from Referral Notes)
Chief Complaint
- Episodes of rotatory vertigo on sitting up, lasting few minutes, for 1 month duration
- Currently resolved to dizziness (non-rotatory)
- Fall while experiencing vertigo approximately 2 weeks ago
Comorbidities (significant and extensive)
| Condition | Relevance to Vertigo |
|---|---|
| Hypertension (BP: 180/56 mmHg at visit) | Uncontrolled - can cause brainstem hypoperfusion, contributing to dizziness |
| Diabetes Mellitus | Peripheral neuropathy, autonomic dysfunction - impairs balance |
| CAD - Post PTCA (Coronary Angioplasty) | Cardiovascular disease - cardiogenic dizziness possible |
| Cervical Spondylosis | Cervicogenic dizziness, proprioceptive impairment |
| Chronic Hyponatremia (Na: 132 on 23 May 2026; Na: 141 on Feb 2026) | Electrolyte imbalance - major contributor to dizziness/unsteadiness |
| Anemia (Hb: 11.5 g/dL Feb 2026) | Mild anemia - reduced cerebral oxygen delivery |
| Carcinoma Bladder | Possible medications, metabolic effects |
| Vitamin D Deficiency (Vit D: 42 Feb 2026) | Border-line low; can affect neuromuscular function and balance |
| Urine ACR: 5174 (Feb 2026) / 152 (May 2026) | Likely diabetic nephropathy |
Vital Signs at Visit
- BP: 180/56 mmHg - Significantly elevated systolic; widened pulse pressure
- Pulse: 51/min - Bradycardia (possibly drug-related - beta-blockers/flunarizine side effect)
- SpO2: 98% - Normal
- Fall Risk Assessment: 1 - Low-medium fall risk noted, though she already fell
III. EXAMINATION FINDINGS (Neurologist's Notes)
- No Nystagmus at rest
- No FND (No Focal Neurological Deficits)
- No Cerebellar Signs
Clinical significance: Absence of spontaneous nystagmus, FND, and cerebellar signs at time of examination argues against an acute central lesion. This supports a peripheral vestibular etiology, consistent with the clinical diagnosis of Peripheral Vertigo / ?BPPV.
IV. VNG (VIDEONYSTAGMOGRAPHY) REPORT ANALYSIS
(Done: 29 July 2026, Priority Hearing Care Pvt. Ltd. - Patient ID: CCDA00412)
A. Oculomotor Assessment
1. Saccade Test
| Parameter | Right Eye | Left Eye | Normal Range | Interpretation |
|---|---|---|---|---|
| Horizontal Velocity | 168.74°/s | 258.35°/s | ~300-600°/s | Low velocity bilaterally - reduced saccadic speed |
| Horizontal Latency | 124.44 ms | 240 ms | ~180-200 ms | Left eye latency prolonged |
| Horizontal Precision | 20.38 | 19.61 | <25° ideally | Mildly abnormal - hypometria |
| Vertical Velocity | 239.78°/s | 210.97°/s | ~200-400°/s | Low-normal |
| Vertical Latency | 265 ms | 275 ms | ~200 ms | Both prolonged |
| Vertical Precision | 40.57 | 28.02 | - | Abnormal vertical precision |
Interpretation: Reduced saccadic velocity and prolonged latencies, particularly in the left eye and in vertical saccades. In an 86-year-old, some slowing is expected with aging. However, the asymmetry (left eye latency 240 ms vs right 124 ms for horizontal) and prolonged vertical latencies deserve attention. Per K J Lee's Otolaryngology - "Abnormal saccades or saccadic pursuit results, especially with normal caloric results" are among findings suggestive of central pathology.
2. Smooth Pursuit Test
| Direction | Right Eye Gain | Left Eye Gain | Normal (Adult) | Interpretation |
|---|---|---|---|---|
| Rightward | 0.39 | 0.34 | >0.7 | Markedly reduced |
| Leftward | 0.58 | 0.45 | >0.7 | Reduced |
| Upward | 0.70 | 0.51 | >0.6 | Borderline - right acceptable |
| Downward | 0.27 | 0.22 | >0.6 | Markedly reduced |
Interpretation: Smooth pursuit gain is globally reduced, most severely in the horizontal rightward and vertical downward directions. In elderly patients, some smooth pursuit degradation occurs normally, but gain values of 0.27-0.39 are significantly below age-adjusted norms. Reduced pursuit gain can indicate either aging-related cerebellar decline or a central vestibular/cerebellar pathway problem. The downward pursuit reduction is particularly noteworthy, as this is a common early sign of central pathology.
3. Optokinetic Test (OKN)
| Stimulus | Right Eye Gain | Left Eye Gain | Interpretation |
|---|---|---|---|
| Left-to-Right (Horizontal) | 0.89 | 0.88 | Normal |
| Right-to-Left (Horizontal) | 0.99 | 1.04 | Normal |
| Top-to-Bottom (Vertical) | 0.66 | - | Mildly reduced |
| Bottom-to-Top (Vertical) | 0.91 | 1.01 | Normal |
Interpretation: Optokinetic nystagmus responses are largely preserved and symmetric for horizontal stimuli (gains ~0.89-1.04). The top-to-bottom vertical OKN is mildly reduced but not pathological. Normal symmetric OKN responses suggest intact brainstem visual-vestibular pathways. This is reassuring and argues against a significant central lesion.
B. Nystagmus Assessment
4. Spontaneous Nystagmus - In Light
- No nystagmus detected (Slow Phase Velocity: -, Amplitude: -, Frequency: -)
- Normal finding
5. Spontaneous Nystagmus - In Dark
- No nystagmus detected
- Normal finding - rules out ongoing peripheral vestibular asymmetry
6. High Frequency Head Shake Nystagmus
- No nystagmus detected
- Normal - no post-head-shake nystagmus, which would typically indicate a unilateral peripheral vestibular lesion (e.g., vestibular neuritis)
7. Hyperventilation-Induced Nystagmus
- No nystagmus detected
- Rules out demyelinating lesion (e.g., acoustic schwannoma, MS plaques) which can produce hyperventilation-induced nystagmus
C. Gaze Tests
8. Gaze Nystagmus - With Fixation (all 5 positions)
- All five positions: No nystagmus detected
- No gaze-evoked nystagmus in center, left, right, up, or down gaze
- Normal - rules out gaze-paretic nystagmus (a central sign)
9. Gaze Nystagmus - Without Fixation
Key Abnormal Finding:
| Position | R Eye SPV | R Eye Amplitude | L Eye | FPD | Frequency |
|---|---|---|---|---|---|
| Center | - | - | - | - | - |
| Left gaze (eyes left) | 6.76°/s | 5.50° | - | 326.55° (oblique) | 1.20 Hz |
| Up | - | - | - | - | - |
| Right | - | - | - | - | - |
| Down | - | - | - | - | - |
Critical Finding: Nystagmus detected in LEFT gaze position WITHOUT fixation in the RIGHT eye only.
- SPV: 6.76°/s, amplitude 5.5°, fast phase direction 326.55° (upper-right oblique direction), at 1.20 Hz
- Absent from the left eye
- Present ONLY on left lateral gaze, disappears with other gaze positions
Interpretation: This is a direction-fixed, gaze-position-dependent nystagmus appearing only on left lateral gaze without fixation. Direction-fixed nystagmus is consistent with peripheral vestibular pathology. The fact that it suppresses with fixation further supports peripheral origin (intact fixation suppression = peripheral sign per K J Lee's Otolaryngology). The oblique fast phase (326°) has a slight upward component alongside horizontal.
D. Subjective Visual Vertical (SVV)
| Condition | Trial 1 | Trial 2 | Significance |
|---|---|---|---|
| Clockwise rotation | +6° (Right) | +6° (Right) | Tilted right |
| Anticlockwise rotation | -5° (Left) | -6° (Left) | Normal recovery |
| Blank background | -2° (Left) | 0° | Near-normal |
Interpretation: SVV on clockwise trials shows consistent 6° rightward tilt, which is mildly abnormal (normal: ±2.5° in blank background). The blank-background trials are normal (0° and -2°). When a tilt stimulus is present, the vestibular system is being challenged and shows mild bias. A persistent SVV tilt >2.5° in blank background would suggest utricular dysfunction, but here the blank background tests are essentially normal.
No caloric testing (bithermal caloric test) results are present in this VNG report. This is an important limitation. Caloric testing is the gold standard for identifying unilateral canal paresis or directional preponderance. Its absence means unilateral vestibular hypofunction cannot be conclusively ruled in or out.
V. INTEGRATED CLINICAL DIAGNOSIS
Primary Diagnosis
Peripheral Vestibular Dysfunction - Most Consistent with Resolving/Atypical BPPV in the Setting of Multifactorial Dizziness of the Elderly
Supporting Evidence for Peripheral Vestibular Etiology
| VNG Finding | Clinical Significance |
|---|---|
| No spontaneous nystagmus in light or dark | No ongoing peripheral or central vestibular imbalance |
| No head-shake nystagmus | No acute unilateral peripheral deficit (e.g., vestibular neuritis) |
| No hyperventilation nystagmus | Against demyelinating/retrocochlear lesion |
| No gaze-evoked nystagmus with fixation | Against cerebellar gaze palsy |
| Direction-fixed nystagmus in left gaze without fixation | Consistent with peripheral vestibular pathology |
| Fixation suppresses the nystagmus | Classic peripheral sign |
| Normal symmetric OKN | Intact brainstem visual-vestibular pathways |
Features Warranting Central Vigilance
| Finding | Why Important |
|---|---|
| Saccade abnormalities - low velocity, prolonged latencies (esp. vertical) | Abnormal saccades with otherwise normal study = possible central involvement per otolaryngology references |
| Globally reduced smooth pursuit gain (horizontal 0.34-0.58; vertical downward 0.22-0.27) | Can be aging-related OR indicate cerebellar/central pathway compromise |
| No caloric test performed | Cannot exclude unilateral canal paresis; limits confidence in purely peripheral diagnosis |
| Age 86, HTN 180/56, Post-PTCA, CAD | High vascular risk; vertebrobasilar TIA/posterior circulation events must always be considered |
| Oblique fast phase component (326° = upper-right) | Pure horizontal nystagmus is more typical of BPPV; oblique/vertical components can indicate central cause |
BPPV Diagnosis Assessment
The clinical presentation (brief rotatory vertigo on sitting up, lasting minutes, now resolved) is consistent with BPPV, particularly posterior canal BPPV. However:
- VNG shows no positional nystagmus was tested (Dix-Hallpike / roll test not documented in this report)
- Symptoms lasted "few minutes" - classic BPPV typically lasts <1 minute per episode; "few minutes" duration is slightly atypical
- The current symptom being just "dizziness" (not vertigo) suggests resolution or transition
Differential Diagnosis (by likelihood)
- Resolving BPPV (posterior/horizontal canal) - Most likely for acute presentation; currently resolving - High probability
- Multifactorial Dizziness of the Elderly (presbyvestibulopathy) - Very likely contributing given age 86, DM, HTN, cervical spondylosis, hyponatremia - High probability concurrent diagnosis
- Cervicogenic Dizziness - Known cervical spondylosis; can cause dizziness and instability - Likely contributor
- Metabolic Dizziness - Chronic hyponatremia (Na 132 as recently as May 2026), anemia, Vit D insufficiency - Active contributor
- Vertebrobasilar TIA/posterior circulation event - Age, vascular risk factors, fall during vertigo episode; cannot fully exclude without MRI - Must rule out
- Vestibular Migraine - Less likely at this age without history
- Central Vestibular Lesion (cerebellar infarct, demyelination) - Low probability given normal gaze/OKN, but saccade/pursuit abnormalities keep this in the differential until MRI confirms
VI. MEDICATION ANALYSIS
| Drug | Class | Rationale | Comment |
|---|---|---|---|
| Migarid 5mg (Flunarizine) | Calcium channel blocker / vestibular suppressant | BPPV/vestibular vertigo | Appropriate for vestibular suppression; CAUTION in elderly - can cause parkinsonism, depression, sedation; Pulse 51/min may relate |
| Ginkocer Plus (Ginkgo Biloba + Ginkgocer) | Cerebrovascular / anti-platelet-activating-factor | Dizziness, cerebrovascular insufficiency | Used for vestibular improvement; modest evidence |
| Vertin 16mg (Betahistine) | H1/H3 histamine agonist/antagonist | BPPV / Meniere's / peripheral vertigo | SOS basis appropriate; good safety profile; helps endolymphatic fluid regulation |
| Stugeron stopped | Previous flunarizine/cinnarizine equivalent | Switching to Migarid (flunarizine) avoids duplication | Appropriate |
VII. RECOMMENDED NEXT STEPS (Based on Investigations Advised)
Already Advised by Neurologist:
-
MRI Brain Plain (Routine) - Essential to rule out posterior fossa lesion, cerebellar infarct, or brainstem demyelination. Given age 86 and vascular risk factors, this is non-negotiable. The saccade and smooth pursuit abnormalities on VNG add urgency to this investigation.
-
VNG - Completed (this report). Key gap: Bithermal caloric test was not performed. This is the single most important missing piece. Requesting caloric testing will:
- Quantify unilateral canal paresis (if any)
- Calculate directional preponderance
- Confirm or refute peripheral vs. central categorization
Additional Suggestions:
- Dix-Hallpike and Roll Test - Should be performed clinically if not already done; these are bedside gold standard for BPPV confirmation. If positive, Epley's maneuver (posterior canal BPPV) or Barbecue/Gufoni maneuver (horizontal canal BPPV) can be curative.
- Repeat Serum Sodium - Chronic hyponatremia (Na 132 in May 2026) is an underappreciated but important cause of dizziness and fall risk in elderly patients.
- ECG / Holter - Pulse 51/min (bradycardia) + CAD + post-PTCA: cardiogenic syncope/presyncope contributing to "fall while experiencing vertigo" must be excluded.
- Postural Blood Pressure - BP 180/56 with widened pulse pressure in elderly; orthostatic hypotension on sitting up could be mimicking or contributing to positional dizziness.
- Vestibular Rehabilitation Therapy (VRT) - Once acute phase is managed, VRT is evidence-based for elderly patients with vestibular dysfunction and falls.
VIII. VNG SUMMARY TABLE
| Test | Result | Interpretation |
|---|---|---|
| Saccades (horizontal) | Reduced velocity; prolonged latency (L eye) | Mildly abnormal; possible aging + central |
| Saccades (vertical) | Prolonged latency bilaterally | Abnormal; central vigilance |
| Smooth Pursuit | Globally reduced (0.22-0.58) | Abnormal; aging vs. central |
| Optokinetic Nystagmus | Normal symmetric | Intact brainstem pathways |
| Spontaneous Nystagmus (light/dark) | Absent | Normal |
| Head Shake Nystagmus | Absent | No unilateral peripheral loss |
| Hyperventilation Nystagmus | Absent | No retrocochlear/demyelinating lesion |
| Gaze Nystagmus (with fixation) | Absent all positions | Normal |
| Gaze Nystagmus (without fixation) | Present in left gaze, right eye only, oblique | Mildly abnormal - peripheral pattern |
| Subjective Visual Vertical | Blank BG: 0°/-2° (normal); stimulated: 6° tilt | Normal at rest; mild dynamic utricular asymmetry |
| Caloric test | Not performed | Missing - must be requested |
IX. CLINICAL BOTTOM LINE
Mrs. Usha Goswamy is an 86-year-old woman with a 1-month history of positional rotatory vertigo (now resolving to dizziness), a fall, and an extensive comorbidity burden. The working diagnosis of Peripheral Vertigo / ?BPPV is supported by the VNG showing absent spontaneous nystagmus, intact fixation suppression, and direction-fixed positional nystagmus pattern. However, the abnormal saccadic metrics (especially prolonged vertical latencies) and markedly reduced smooth pursuit gains introduce caution regarding a concurrent central component. MRI brain is mandatory before finalizing a purely peripheral diagnosis. Caloric testing is the critical missing component of the VNG evaluation. Metabolic contributors - particularly chronic hyponatremia and anemia - must be optimized. Fall risk management is high priority given her age, vascular history, and documented fall.
Sources: K J Lee's Essential Otolaryngology (ENG/VNG Interpretation, p.351); Scott-Brown's Otorhinolaryngology (Vestibular Testing); Cummings Otolaryngology (BPPV); Clinical data from Max Healthcare referral and VNG report dated 29 July 2026.
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