Physio Vestibular Initial assessment

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.