Vestibular Initial

Section: Patient Information * Name: John Smith * Date of Birth: 12/03/1960 * Address: 12 High Street, Anytown, AB1 2CD * Contact Information: 01234 567890 Employment status: Retired. Physical demands of job: Previously a builder, now sedentary. Work-related activities: None. General exercise and activity levels: Walks the dog daily, otherwise mostly sedentary. Section: Medical History * Hypertension * Osteoarthritis * Benign Paroxysmal Positional Vertigo (BPPV) - treated successfully 2 years ago. Details of previous vestibular or neurological treatments/surgeries: Treated for BPPV with canalith repositioning maneuver 2 years ago. No other treatments. Allergies: * Penicillin Medications: * Lisinopril 10mg daily Family medical history of conditions that may impact vestibular function: Mother had a history of Meniere's disease. Section: Social History Relevant social history: Lives in a bungalow. No history of falls in the last year. Drinks alcohol socially, smokes 10 cigarettes a day. Section: Current Condition/Complaint Detailed description of dizziness, vertigo, imbalance, nausea, falls, etc.: Reports episodes of room spinning vertigo lasting seconds, triggered by rolling over in bed. Also reports mild imbalance when walking, especially in the dark. No nausea or falls. Date of onset or specific triggering event: Symptoms started 2 weeks ago. Description of how symptoms began: Woke up with a sudden spinning sensation. Details of prior vestibular therapy, ENT/neuro assessments, or other relevant interventions: None. Describe symptom pattern, frequency, duration, aggravating/easing factors: Vertigo episodes occur 2-3 times per day, lasting 10-20 seconds. Triggered by head movements. Symptoms are worse in the morning. No specific easing factors identified. Section: Patient Goals Short-term physiotherapy goals and time frame: * Reduce frequency and intensity of vertigo episodes within 2 weeks. * Improve balance during daily activities within 2 weeks. Long-term physiotherapy goals and time frame: * Prevent recurrence of vertigo episodes. * Maintain balance and independence in daily activities. Section: Objective Vestibular assessment findings including oculomotor exam, positional tests, balance and gait testing, motion sensitivity, symptom reproduction: * Oculomotor exam: Normal smooth pursuit and saccades. * Positional tests: Positive Dix-Hallpike test on the right side. * Balance and gait testing: Mild postural instability. * Motion sensitivity: Mild sensitivity to head movements. * Symptom reproduction: Vertigo reproduced with Dix-Hallpike maneuver. Rating scales used: * Dizziness Handicap Inventory (DHI): Score of 24 (mild handicap). Section: Treatment Subsection: Education Education provided about vestibular system, cause of symptoms, role of rehab: Explained the vestibular system and the cause of BPPV. Discussed the role of physiotherapy in managing symptoms and improving balance. Subsection: Hands-on treatment (if applicable) Manual techniques such as canalith repositioning maneuvers or instructions for home-based maneuvers: * Performed Epley maneuver on the right side. Subsection: Active therapy / exercises provided in-session List of vestibular exercises administered, including dosage/frequency if relevant: * Habituation exercises: 3 repetitions of each exercise, 3 times a day. Section: Assessment Clinical impression: Benign Paroxysmal Positional Vertigo (BPPV) affecting the right posterior semicircular canal. Prioritized problems: * Vertigo episodes. * Imbalance. Progress toward goals: Patient reported a slight reduction in vertigo episodes after the Epley maneuver. Barriers: None identified. Section: Plan Ongoing vestibular rehab focus areas such as habituation, adaptation, balance retraining: Continue with habituation exercises and balance retraining. Recommended frequency and duration of therapy: Follow-up in 1 week. Home exercise program details including dosage/frequency: * Brandt-Daroff exercises: 5 repetitions, 3 times a day. * Balance exercises: Standing on one leg, 30 seconds, 3 times a day. Safety strategies at home if applicable: Advised to avoid sudden head movements and to use a walking aid if needed. Consider referral if red flags or poor response to treatment: Monitor progress and consider referral to an ENT specialist if symptoms worsen or do not improve.