Practice Case:

Vestibular dysfunction

Brainstorming: What do you know about the case?

Write down anything and everything that you know about Acute Stroke. Discuss with your
group mates how each of the items written here are related to each other and, as a whole,
explain the nature of this condition.

S> P.M., a 45 y/o male, (R) handed, (-)HTN/DM/Asthma, was referred for PT evaluation and rx 2
c/o dizziness and vestibular problems with a diagnosis of (R) canalithiasis. Pt states that he
is unable to work as a laborer and cannot even walk well because of dizziness. Riding a jeep
causes him to feel nauseated and recalls vomiting after being stuck in traffic for 2 hrs. He
states that he is already dizzy when he wakes up after sleeping on the right side . HPI: 7
days PTC, pt reports that he was working in construction carrying concrete hollow blocks
when he tripped and hit his head on the pavement. He states that he was wearing his hard
hat and was thankful that it protected his head. No bruising or loss of consciousness was
reported. He consulted with a physician 4 hrs later because he felt dizzy. An x-ray was taken
which showed no abnormalities. He returned to see the same MD 2 days later because he
continued to have dizziness when turning his head and looking down. The physician after
further examination told him that it was his inner ear and gave him a prescription for
Bonamine (Meclizin HcL) 50 mg twice a day for his dizziness. The medication has helped
decrease the severity of the dizziness but still persists until PT consult. PMHx: Pt has had no
previous hospitalizations, no fractures, nor does he report of being involved a car accident.
Family Hx: Father was a diabetic and had kidney failure. Mother had HTN and died of

University of Santo Tomas- College of Rehabilitation Sciences

cancer. Both are deceased. Two other siblings have HTN . Lifestyle: Pt is (+) smoker; 1
pack/day and a social drinker, who works as a clerical personnel in a law firm. Social and
Physical Environment: Pt. is married with 2 children. He lives in a rented one story house
with 1 bedroom and bathroom. Wife earns a living by selling fish in the local market.. Pts
Goal: To be able to work again without dizziness.
O:
VS> BP: a: 130/70 mmHg
> PR: a: 75bpm
> RR: a: 18 cpm
>T: 37.2 C
OI > ambulatory
ectomorph
(-) abrasions on the scalp or face
(-) trophic skin changes on all 4s
Palpation > Normothermic on all 4s
normotonic on (L) UE/LE
(+) muscle guarding on (B) upper trapezius, SCM and paracervical
(-) tightness on all 4s
(-) tenderness on all 4
ROM > All major joints of (B) UE/LE are WNL, actively & passively done, painfree & c N endfeels
except Cervical spine ROM is functional with patient complaining of increased dizziness
when turning head to the right and to the left. Lumbar spine ROM is complete with
increased symptoms when bending forward and returning to neutral
MMT > All major muscles of (B) UE/LE & neck muscles are grossly graded 5/5
Neurologic Evaluation:
Cerebrum > conscious, alert, coherent, cooperative
Oriented as to person, place & time
(+) long & short term memory
CN > Cranial nerves were intact except that the patient had nystagmus when following the
therapist's finger from side to side.
Special Test: (+) Dix-hall pike test on the
PA> Head is held slightly rotated to the left 10 degrees and laterally flexed to the right 5.
Shoulders are level. No lateral curvature of the spine is noted. There is slight decrease of
cervical curvature. Neither kyphosis nor lordosis is present.
FA> Independent in all aspects in basic ADLs, but with mod difficulty in bed mobility from supine
to sit d/t dizziness.

Guide Questions for the Written Report:

What findings point to the medical diagnosis?

diagnosis?

Do all findings consistently support the

University of Santo Tomas- College of Rehabilitation Sciences

Differential Diagnosis:
Give other medical conditions that you may want to rule out in this case. Give at least one
specific finding that will support the presence of each of these conditions.

Continuation of Guide Questions for the Written Report:

Are there additional examination procedures that should have been done to confirm the
diagnosis?
What is your physical therapy diagnosis for this case?
What is the prognosis of this patient?
Which of these abnormal findings could be addressed by physical therapy intervention?
Classify these findings as impairments, limitations of activity and participation restriction.
Develop a diagram indicating the relationships (using arrows) of the different impairments,
activity limitations and participation restrictions that you will address in the case.
Which among the problems listed should take priority over the others? Explain your
intervention scenario for the case.

Prioritization in Other Case Situations:

Explain and/or cite examples on how problems and their prioritization will differ across
these stages.

Continuation of Guide Questions for the Written Report:

What functional outcomes do you expect from this patient?

Translate these expected outcomes to long term goals. Remember to formulate rehabilitative
and/or preventive goals.

University of Santo Tomas- College of Rehabilitation Sciences

What skills or activities will be pre-requisites to achieving your functional outcomes?

Formulate short-term goals for the top five problems in your list.

Progressing Your Goals:

In diagram format, show how you will progress your STG from the first day of treatment up
to discharge.

Continuation of Guide Questions for the Written Report:

Give five most important treatment procedures (aside from HEP and Patient Education
activities) that you will use for this patient. Remember to include one treatment modality that
will be most useful for this case.
What will be the specific parameters you will use for each of the treatment procedure?
How will you sequence the treatment procedures so that they are carried out in a logical and
efficient manner?

Incorporating Evidence into Your Practice:

Find a journal article that discusses the effectiveness of any PT intervention that you can
use for any of the problems related to vestibular dysfunction. Briefly describe the following:
Objectives
Methods
Results
Conclusions
Relevance to Vestibular dysfunction

University of Santo Tomas- College of Rehabilitation Sciences