Physio Vestibular Initial assessment

S// PC **Symptoms:** [Detailed description of the patient's current symptoms. Use the language the patient uses to describe their symptoms.] - **Dizziness:** [List any dizziness symptoms. E.g. horizontal/vertical spinning, rocking, lightheadedness. If there are none, state nil.] - **Visual:** [Describe any visual symptoms. E.g. blurred vision, oscillopsia, photophobia, loss of vision, double vision. If there are none, state nil.] - **Balance:** [Describe any balance symptoms. E.g. unsteady on feet, veering to one side, falls, feeling drunk. If there are none, state nil.] - **Ear:** [Describe any ear symptoms. E.g. hearing loss, aural fullness, tinnitus. If there are none, state nil.] - **Neck pain:** [Describe any neck pain, including its location, severity and correlation to other dizziness symptoms. E.g. Right innerment upper cervical pain that correlates with dizziness. If there are none, state nil.] - **Headache:** [Describe any headache, including its location, severity and correlation to other dizziness symptoms] - **Nausea/vomiting:** [Describe any nausea or vomiting that has occurred. E.g. nausea accompanying more severe dizziness spells, nil vomiting. If there are none, state nil.] **- Drop attacks: **[Describe any drop attacks that have occurred, including any loss of consciousness or feeling faint. If there are none, state nil.] - **Other** (red flags): [Describe any other symptoms discussed that do not fit the above categories. e.g. numbness or tingling in the limbs, difficulties speaking, difficulties swallowing, difficulties coordinating movement, incontinence, muscle weakness, facial asymmetry If there are none, state nil] **Consistency:** [Detail whether the symptoms are constant, episodic or constant at varied intensity in nature] **Episode frequency & Duration:** [Describe the episode frequency and duration of episodes] (only include if symptoms are episodic in nature, omit if symptoms are continuous. **Agg:** - Positions/ movements: [Detail any positions/movements that aggravate symptoms. E.g. rolling in bed, looking up/down, quick head turns, bending over, getting out of bed, general walking/ moving around. If there are none, state nil.] - Environments: [Detail any other factors that aggravate symptoms. E.g. driving, escalator, loud sounds, light, TV, crowds, dark, work. If there are none, state nil] - Other: Detail any other aggravating factors, including if symptoms are worse at a particular time of the day. If there are none, omit this line.] **Ease:** - [Detail any factors that reduce symptoms e.g. stemetil, not moving head, visual spotting with walking. If there are none, state nil] **HPC: ** -** DOI: **[Date of onset and/or date of surgery] (You can say in more generalised terms e.g. >3 years, if a specific date hasn't been given) - **Onset: **[Detailed description of how the symptoms first began. E. g. first noticed left upper cervical neck pain at work then dizziness progressively worsened over hour] - **Precursor:** [Detail if a virus/cold/ head trauma/scuba diving occurred prior to the symptoms onset. If there are none, state nil virus/head/ barotrauma] - **Progression:** [Describe progression of complaint and nature of symptoms, and if symptoms are generally worsening, improving or stagnant.] - **Prior Intervention: **[Details of any prior therapy, interventions, and/or surgery e.g. saw GP, thought might be BPP, told to see physio. If none are mentioned, state nil] - **Radiology: **[Detail any radiology assessment, their findings, and detail what imaging clinic the assessment was conducted with. If nil has been completed, state nil] **PMH:** - **Medical conditions/medications: **[List medical conditions and allergies, and the medication taken for each condition. List any injuries] (If non are mentioned, state Nil) ○ Vestibulotoxic substance; [Describe any pre-existing history of chemotherapy, history of antibiotic use in particular gentamicin, streptomycin] (If non are mentioned, state Nil) ○ Vision Issues: [Describe any pre-existing vision issues e.g. glasses, contact lenses, convergence insufficiency] (If non are mentioned, state Nil) ○ Peripheral Neuropathy: [List if the patient has peripheral neuropathy, and whether they got it from diabetes or chemotherapy] (If non are mentioned, state Nil) ○ Mobility/falls: [Describe any pre-existing walking aids uses, falls, history and mobility equipment set up in house.] (If non are mentioned, state Nil) ○ Cervical Pain: [Describe any pre-existing history of neck pain. (If non are mentioned, state Nil) ○ Migraines: [Describe migraine history if stated.] (If non are mentioned, state Nil) - **Prior vestibular episodes: **[Describe any prior dizziness/ vestibular episodes and the diagnosis and treatment given] (If non are mentioned, state Nil) **SHx:** - **Occ:** [Summarise employment status, occupation, hours work e.g. full/ part time, physical/mental intensity of job, etc.] (if retired, stated retired) - **Exercise: **[Detail exercise, sport and activity levels. Detail what exercise on what day of the week, with detail what parts or days of the exercise that are most important and can't be missed . Detail any competition or goal working towards. State nil if the patient doesn't do any] - **Goals:** [physiotherapy goals & time frame for achieving these goals] (State nil if the patient doesn't have any) - **Other:** [Mention relevant social history like lifestyle factors, living arrangements, support network, tobacco/alcohol use, etc.] [Detail any distress, concerns, worries, or impact the injury has on their life.] O// - **Observation**: [posture: normal/forward head/cervical stiffness. Facial symmetry] (Only include posture: normal/forward head/cervical stiffness if it has been explicitly mentioned in the transcript, contextual notes or clinical note; otherwise, omit completely.) - **Gait:** [gait: NAD/wide-based gait/ataxic gait] - **Cervical AROM:** [cervical AROM: normal/reduced] -** Sustained Cx Rot:** [sustained cervical rotation: nil symptoms/symptoms] **Oculomotor assessment/ CNS** - **Spontaneous Nystagmus **(with/without fixation): [spontaneous nystagmus (with/without fixation): present/absent. Fast phase: ] - **Gaze evoked nystagmus:** [gaze evoked nystagmus: nil change/worse right/worse left] -** Smooth Pursuits: **[smooth pursuits: normal/saccadic intrusions] - **Saccades: **[saccades: normal/delayed/saccadic intrusions/under/overshooting] - **VOR Suppression:** [VOR suppression: normal/impaired/saccadic intrusions] - **Skew test: **[Skew Test: hypertropia, hypotropia, exophoria] - **Visual field:** [Visual field: Normal, reduced] - **Cranial nerves:** NAD. - **Cerebellar tests:** [cerebellar tests: rapid finger nose, heel skin, supinate/pronate] (only include cerebellar tests (if indicated): rapid finger nose, heel skin, supinate/pronate if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) **VOR Assessment: ** - **HIT**: [head impulse test: normal/abnormal (L/R/bilateral)] - **DVA: **[dynamic visual acuity (DVA): normal/impaired (>3 lines above)] (only include dynamic visual acuity (DVA): normal/impaired (>3 lines above) if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) **- Fukuda Step test:** [Fukuda Step test: Normal/ Abnormal- if abnormal list the degrees rotated and distance from starting position] **Positional/BPPV Assessment:** - **Dix-Hallpike Test: ** - Right: [List right dix-hallpike assessment results, including if positive or negative, onset latency, fatiguability and nystagmus direction] - Left: [List left dix-hallpike assessment results; including if positive or negative, onset latency, fatiguability and nystagmus direction] - **Roll Test:** [roll test: positive/negative (L/R)] (only include roll test: positive/negative (L/R) if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - Right: [List right roll test assessment results, including if positive or negative, onset latency, fatiguability nystagmus direction i.e. geotropic/ageotropic, and nystagmus strength] - Left: [List left roll test assessment results; including if positive or negative, onset latency, fatiguability, nystagmus direction i.e. geotropic/ageotropic, and nystagmus strength] **Balance & Postural Control** -** SLS**: [single leg stance: >10sec /impaired] - **Romberg**: [romberg/ sharpened romberg test. Feet together eyes open: >10sec /abnormal, FT eyes closed >10sec/abnormal, Tandem EO >10sec/abnormal, T EO: >10sec/abnormal] - **CTSIB**: [CTSIB: Floor eyes open: >30sec /abnormal. Floor eyes closed >30sec /abnormal. Foam EO >30sec /abnormal. Foam EC: >30sec/abnormal] - **DGI:** [dynamic gait index (DGI): **/24] **Walk on a level surface, change walking speed, walk while turning the head horizontally, walk while turning the head vertically, perform a pivot turn, step over and around obstacles, and navigate stairs. Each task gets a score out of 0-3, 3 being normal, 0 sever impairment. - **TUG**: [timed up and go (TUG): sec (normal/slow) A// **PC:** [Duration, progress, primary symptoms. E.g. 3/12 worsening unsteadiness and vertigo] **Dx**: [Diagnosis given. E.g. L BPPV] (if a second injury/ pain is mentioned, repeat this line) - Differential: (state any differential diagnosis e.g. unilateral vestibular hypofunction) - Key CF: (state key contributing factors e.g. diabetes, viral infection, chemotherapy, age-related reduced baseline balance) **B/G:** [State any barriers affecting progress, important medical conditions/treatment contraindications, goals, preferences, sporting/work considerations] I// **Edu/Advice:** - [List all educational and advice that was provided throughout session] - [Summary of the clinical plan until the next appointment] **Manual Tx: **[List all hands-on treatment provided throughout the session. Include the response to reassessment is mentioned] - [e.g., PAIVM Gr III R) C5/6 x2x30s] - [e.g., STM L) upper traps 5mins] - [e.g. CRM L) x2//reduced symptoms] (Put each different treatment on a separate line) **HEP: **[List home exercise program [HEP] provided] (Include reps, sets and frequency) **Communication:** [Referrals, Letters, phone calls or communication to other professionals] (Only include if explicitly mentioned) **R//** [State when next appointment should be e.g, 2/52] [Detail any stated therapy plan for the next appointment and any information that I will follow up for the next appointment] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) capture all the relevant information from the transcript.)