S//
PC
**Symptoms:** The patient reports experiencing episodes of dizziness, described as a spinning sensation, particularly when turning their head quickly. They also report experiencing some unsteadiness on their feet.
- **Dizziness:** Horizontal spinning, worse with head turns.
- **Visual:** Nil.
- **Balance:** Unsteadiness on feet.
- **Ear:** Nil.
- **Neck pain:** Mild right-sided neck pain, upper cervical region.
- **Headache:** Nil.
- **Nausea/vomiting:** Nil.
- **Drop attacks:** Nil.
- **Other** (red flags): Nil.
**Consistency:** Episodic.
**Episode frequency & Duration:** Episodes occur approximately 2-3 times per week, lasting for a few minutes each time.
**Agg:**
- Positions/ movements: Quick head turns, rolling over in bed.
- Environments: Nil.
- Other: Nil.
**Ease:**
- Nil.
**HPC: **
-** DOI: **>6 months.
- **Onset: **Patient first noticed dizziness after a bout of the flu, with symptoms gradually worsening over time.
- **Precursor:** Flu.
- **Progression:** Symptoms have gradually worsened over the past six months.
- **Prior Intervention: **Saw GP, referred to physiotherapy.
- **Radiology: **Nil.
**PMH:**
- **Medical conditions/medications: **Nil.
○ Vestibulotoxic substance; Nil.
○ Vision Issues: Wears glasses for reading.
○ Peripheral Neuropathy: Nil.
○ Mobility/falls: Nil.
○ Cervical Pain: Nil.
○ Migraines: Nil.
- **Prior vestibular episodes: **Nil.
**SHx:**
- **Occ:** Works full-time as an office administrator.
- **Exercise: **Walks for 30 minutes, 3 times a week.
- **Goals:** To reduce dizziness and improve balance.
- **Other:** Smokes 5 cigarettes a day.
O//
- **Observation**: Posture: normal.
- **Gait:** NAD.
- **Cervical AROM:** normal.
-** Sustained Cx Rot:** nil symptoms.
**Oculomotor assessment/ CNS**
- **Spontaneous Nystagmus **(with/without fixation): absent.
- **Gaze evoked nystagmus:** nil change.
-** Smooth Pursuits: **normal.
- **Saccades: **normal.
- **VOR Suppression:** normal.
- **Skew test: **Nil.
- **Visual field:** Normal.
- **Cranial nerves:** NAD.
- **Cerebellar tests:** Nil.
**VOR Assessment: **
- **HIT**: normal.
- **DVA: **normal.
**- Fukuda Step test:** Normal.
**Positional/BPPV Assessment:**
- **Dix-Hallpike Test: **
- Right: Negative.
- Left: Negative.
- **Roll Test:** Nil.
- Right: Nil.
- Left: Nil.
**Balance & Postural Control**
-** SLS**: >10sec.
- **Romberg**: FT eyes open >10sec/abnormal.
- **CTSIB**: Floor eyes open: >30sec /abnormal.
- **DGI:** 22/24
- **TUG**: 8 sec (normal)
A//
**PC:** 6/12 worsening unsteadiness and vertigo.
**Dx**: Vestibular Hypofunction.
- Differential: BPPV.
- Key CF: Age-related reduced baseline balance.
**B/G:** Patient is motivated to improve and has good social support.
I//
**Edu/Advice:**
- Explained the nature of vestibular hypofunction and the importance of vestibular rehabilitation.
- Provided education on fall prevention strategies.
- Discussed the importance of regular exercise.
- Provided education on the impact of smoking on vestibular function.
- Discussed the importance of smoking cessation.
- Discussed the importance of smoking cessation.
- Provided education on the impact of smoking on vestibular function.
- [Summary of the clinical plan until the next appointment]
**Manual Tx: **
- CRM L) x2//reduced symptoms
(Put each different treatment on a separate line)
**HEP: **
- Habituation exercises: 3 times a day.
- Gaze stabilization exercises: 3 times a day.
- Balance exercises: 3 times a week.
(Include reps, sets and frequency)
**Communication:** Nil.
**R//**
2/52
Continue with home exercise program. Will review progress and adjust treatment plan as needed.
