VNG (Videonystagmography) Report - Full Analysis with Diagnosis

CLINICAL HISTORY SUMMARY

• Episodic vertigo for 6 months; episodes last 2-3 minutes
• Symptoms: spinning/rotating sensation, unsteadiness, blackout, sensation of falling, nausea, fatigue, double vision
• Triggered by: positional changes (lying-to-sitting, rolling to left side, turning head left), viewing moving objects
• Requires support to stand/walk during episodes
• No photophobia or phonophobia
• Comorbidities: Cervical spondylitis, Hypertension, Parkinson's disease, Diabetes mellitus
• Pure Tone Audiometry: Bilateral mild sensorineural hearing loss

VNG TEST FINDINGS - SYSTEMATIC REVIEW

1. SACCADES (Eye Movement Initiation & Speed)

2. SMOOTH PURSUIT

3. OPTOKINETIC (OKN) TEST

4. SPONTANEOUS NYSTAGMUS

• In Light: No spontaneous nystagmus (Slow Phase Velocity = absent, Amplitude = absent)
• In Dark: No measurable spontaneous nystagmus recorded (values all absent/dashes)

5. GAZE TEST

• No definable slow-phase velocity
• No definable amplitude or frequency values
• Traces show irregular baseline movements (micro-oscillations) without a structured nystagmus pattern

6. DIX-HALLPIKE (Positional Tests)

• Sit Head Right: Large amplitude horizontal and vertical eye movement deflections recorded (right horizontal up to 200°, left vertical down to -160°)
• Supine Head Ext. & Right: Large amplitude deflections (right horizontal up to 200°, left vertical -100°)

• Sit Head Left: Large amplitude deflections (right horizontal ±150°, left vertical -90°)
• Supine Head Ext. & Left: Large amplitude deflections (right horizontal ±110°, left vertical -160°)

• Yaw Right, Yaw Left, Pitch Forward, Pitch Backward, Roll Right, Roll Left: Mild-to-moderate amplitude movements without definitive structured nystagmus pattern

7. SUBJECTIVE VISUAL VERTICAL (SVV)

• SVV deviation of approximately 9° to the right in clockwise condition and 10° to the left in anticlockwise condition
• Normal SVV is within ±2-3°. Deviations exceeding ±2° are considered abnormal.
• The blank background deviation of -2° (Left) is at the upper limit of normal/borderline.
• The wide spread (9°R to 10°L) across conditions suggests vestibular asymmetry and/or poor otolith-ocular reflex regulation, with possible contributions from the Parkinsonian postural control deficit.
• An abnormal SVV (particularly tilt toward one side consistently) would indicate otolith dysfunction (utricle/saccule) or thalamo-cortical vestibular pathway involvement.

COMPREHENSIVE DIAGNOSIS

Primary Diagnosis:

• Supported by: bilateral Dix-Hallpike positional responses with large deflections, episodic short-duration vertigo triggered by positional changes, clinical history of 2-3 minute episodes with head-movement provocation.

Secondary / Overlapping Diagnosis:

• Supported by: severely reduced smooth pursuit gain (bilateral, all directions), markedly prolonged saccade latencies (>400-520 ms bilaterally), reduced vertical OKN responses, and irregular gaze stability in darkness.
• Per K.J. Lee's Essential Otolaryngology: findings suggestive of central pathology include "abnormal saccades or saccadic pursuit results, especially with normal caloric results."

Contributing Factors:

1. Parkinson's Disease - directly contributes to saccadic slowing, pursuit breakdown, impaired VOR cancellation, and postural instability
2. Bilateral Mild Sensorineural Hearing Loss (on PTA) - suggests end-organ aging (presbycusis) with likely concurrent otoconia degeneration predisposing to BPPV
3. Cervical Spondylitis - may exacerbate cervicogenic dizziness and limit head/neck movement during positional testing
4. Hypertension and Diabetes - vascular and metabolic risk factors that can contribute to labyrinthine microvascular insufficiency

SUMMARY TABLE

CLINICAL RECOMMENDATIONS

1. Canalith Repositioning Maneuver (CRM): Epley maneuver for the left posterior SCC (primary symptomatic side). If bilateral BPPV confirmed, treat the more symptomatic side first, then the other after 48-72 hours.
2. Vestibular Rehabilitation Therapy (VRT): Gaze stabilisation exercises and balance retraining, modified for Parkinson's disease limitations (fall risk, rigidity).
3. Neurological Review: Given the significant central oculomotor findings (saccadic slowing, pursuit breakdown), urgent neurology review is recommended for re-evaluation and optimisation of Parkinson's disease management.
4. MRI Brain (with posterior fossa views): To exclude secondary BPPV causes and assess for any posterior fossa lesion contributing to the central VNG findings (particularly brainstem or cerebellar involvement).
5. Caloric Testing: The current VNG battery does not include bithermal caloric results (not present in the report). Caloric testing would be valuable to quantify unilateral canal weakness and complete the peripheral vestibular assessment.
6. Vascular Risk Factor Optimisation: Strict BP and glycaemic control given contributions of hypertension and diabetes to labyrinthine microvascular disease.
7. Fall Risk Assessment: This patient requires a formal falls risk assessment given Parkinson's disease, vertigo episodes, and bilateral vestibular involvement.

Note: This report is based on VNG data (videonystagmography) recorded on 26-May-2026 at Priority Hearing, supplemented by clinical history provided. The impression and signature fields on the cover page are blank - the treating clinician should review and countersign. Final clinical decisions should integrate this report with the full clinical examination and other investigations.

Sources: Adams and Victor's Principles of Neurology, 12th Ed. | K.J. Lee's Essential Otolaryngology | Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol.2

Lab Report Analysis - Full

PAGE 1 - Thyroid, Metabolic & Biochemical Panel

THYROID FUNCTION TESTS

RHEUMATOID FACTOR (RA Factor)

SERUM CALCIUM

SERUM BILIRUBIN

SERUM CREATININE

ALKALINE PHOSPHATASE (ALP)

SERUM URIC ACID

PAGE 2 - Complete Blood Count (CBC)

RED CELL PARAMETERS

• Haemoglobin 11.3 g/dL confirms mild anaemia in this 46-year-old woman (normal ≥12 g/dL for adult women).
• The anaemia is normocytic normochromic (MCV 89.5 fL, MCH 28.5 pg, MCHC 31.8 g/dL) - meaning the red cells are of normal size and colour.
• RDW of 13.8% is at the upper limit of normal, suggesting a mild degree of anisocytosis (variation in red cell size), which can be an early feature of mixed nutritional deficiency.
• Haematocrit of 35.6% is reduced (normal 40-59% in women), consistent with the low Hb.

1. Anaemia of chronic disease (most likely, especially if underlying inflammatory/chronic condition present)
2. Early iron deficiency (before microcytosis develops)
3. Mixed deficiency (iron + B12/folate together can cancel out and produce normocytic picture)
4. Renal insufficiency (creatinine is low here, less likely)
5. Haemolysis (bilirubin normal, less likely)

WHITE CELL PARAMETERS

• Total WBC count is normal - no leucocytosis or leucopenia. No overt infection or immunosuppression.
• Eosinophils at 3.2% exceed the upper reference limit of 1%. This is a mild eosinophilia. In the Indian subcontinent context, this most commonly suggests:
  1. Parasitic infection (intestinal helminths - very common, e.g., Ascaris, hookworm)
  2. Allergic condition (asthma, allergic rhinitis, atopic dermatitis)
  3. Drug hypersensitivity
  • Hookworm infestation is of particular relevance here as it is also a cause of iron-deficiency anaemia (intestinal blood loss), which could explain both the eosinophilia and the anaemia together.

PLATELET PARAMETERS

• Platelets are normal in count (279 × 10³/cu.mm) - no thrombocytopaenia or thrombocytosis.
• MPV (Mean Platelet Volume) is mildly elevated at 10.0 fL (ref: 8-9.5 fL). Elevated MPV indicates larger, more metabolically active platelets, which can be seen in:
  • Iron deficiency
  • Inflammatory conditions
  • Increased platelet turnover
  • Thyroid disease (TSH normal here, so less likely)
• PDW and P-LCR are normal.

PAGE 3 - Liver Function, Renal Function, Electrolytes & Virology

LIVER ENZYMES

SERUM PROTEINS

HEPATITIS B SURFACE ANTIGEN (HBsAg)

RENAL FUNCTION

ELECTROLYTES

• Sodium and chloride are normal. No dysnatraemia or hypochloraemia.
• Potassium at 5.44 mmol/L is at the upper limit of normal (normal upper limit 5.5 mmol/L). This is borderline hyperkalaemia. While technically within range, this level warrants attention because:
  • Values >5.0-5.3 mmol/L in clinical practice are often monitored carefully
  • Could reflect haemolysis during sample collection (a common pseudo-hyperkalaemia cause), or mild renal potassium retention
  • If the patient is on ACE inhibitors, ARBs, NSAIDs, or potassium-sparing diuretics, this needs prompt review
  • ECG correlation recommended if this is a true finding

HAEMOGLOBIN (CBC repeat)

OVERALL SUMMARY & CLINICAL CORRELATION

ABNORMAL / NOTABLE FINDINGS AT A GLANCE

ALL NORMAL

CLINICAL RECOMMENDATIONS

1. For Anaemia (Hb 11.3 g/dL):

• Check serum ferritin, serum iron, TIBC to identify iron deficiency (even with normocytic picture, early iron deficiency is possible)
• Check serum B12 and folic acid (mixed deficiency can present as normocytic anaemia)
• If anaemia is confirmed as iron deficiency, initiate oral iron supplementation (ferrous sulphate 200 mg TDS or equivalent)
• Investigate source: in a 46-year-old woman with eosinophilia, stool examination for ova and parasites is a priority (hookworm = GI blood loss + eosinophilia)
• In a perimenopausal woman, menorrhagia should also be excluded as a cause

1. For Eosinophilia (3.2%):

• Stool microscopy for ova and parasites - high priority in this demographic/geographic region
• If negative, consider allergy panel (IgE levels, skin prick test)
• Deworming with Albendazole 400 mg single dose (after confirming parasitic infection or empirically per local guidelines)

1. For Borderline Potassium (5.44 mmol/L):

• Repeat potassium with careful sample handling (avoid prolonged tourniquet, immediate processing) to exclude pseudo-hyperkalaemia from haemolysis
• Review current medications (NSAIDs, ACE inhibitors, ARBs, potassium supplements)
• ECG if truly elevated or patient has cardiac symptoms

1. For Low Creatinine (0.58 mg/dL):

• No specific action needed unless symptoms of myopathy or muscle wasting present
• Ensure adequate protein intake

1. General:

• All thyroid, liver, renal, and autoimmune (RA) markers are reassuringly normal
• No evidence of hepatitis B, liver disease, rheumatoid arthritis, or thyroid disorder
• Patient can be reassured regarding these systems

Note: This analysis is based on the laboratory values as read from the provided report images. All values should be correlated with the patient's clinical presentation and symptoms. Final clinical decisions should be made by the treating physician. - Sources: Harrison's Principles of Internal Medicine 22nd Ed. | Rosen's Emergency Medicine