Patient Information:
Jane Doe, 01/01/1970, 123 Main Street, Anytown, AB1 2CD, 01234 567890
Employed as a software engineer, primarily desk-based work.
Regular exercise, including brisk walking 3 times per week.
Medical History (if updated):
No new relevant diagnoses or medication changes since the last session.
Subjective Update:
Patient reports occasional dizziness, especially when turning in bed. No vertigo or nausea. Reports mild imbalance when walking in crowded areas. Headaches have reduced in frequency. Visual sensitivity remains unchanged.
No recent falls or near-falls.
Symptom pattern: Turning in bed and walking in crowds provoke symptoms.
Patient reports slight improvement in dizziness since last session.
Adherent to HEP, performing exercises 5 times per week, finds them manageable.
No changes to lifestyle or activity levels.
Patient Goals:
- Reduce dizziness frequency and severity.
- Improve balance and confidence in walking.
- Return to full participation in social activities.
Objective:
- Positional testing: Negative Dix-Hallpike and Roll Test.
- Oculomotor/VOR testing: VOR x1 and x2 within normal limits. Smooth pursuit and saccades intact.
- Balance: Romberg stable. mCTSIB stable on firm surface, mild sway on foam with eyes closed. Single leg stance 15 seconds on each leg.
- Gait assessment: Mild unsteadiness with head turns. Dual tasking slightly impaired.
- Motion sensitivity testing: Mild sensitivity to head movements in the horizontal plane.
- Symptom reproduction/resolution: Mild dizziness reproduced with head turns. No nystagmus or nausea.
- Outcome measures: DHI score 16 (down from 22), ABC score 88 (up from 82), Motion Sensitivity Quotient (MSQ) 12 (unchanged).
Treatment Provided:
Education:
Reinforced explanation of vestibular mechanisms, recovery timelines, and neuroplasticity.
Hands-on Treatment (if applicable):
No manual techniques performed.
Active Therapy / Exercises Performed During Session:
Gaze stabilisation drills, habituation tasks, and dynamic balance retraining.
Assessment:
Patient demonstrates continued progress towards goals, with improved balance and reduced dizziness frequency. Tolerates exercises well. No significant barriers or concerns identified.
Plan:
Continue with current vestibular rehab approach, including progressions in balance and gaze tasks.
Updated HEP: Gaze stabilisation drills (3 sets of 10 reps, 2 times per day), habituation exercises (5 reps of each movement, 2 times per day), and balance retraining (single leg stance, 30 seconds, 2 times per day).
Next review: Reassess DHI in 2 weeks, clinical progress check-in.
Fall prevention advice: Review home safety and fall risk factors.
Patient Information:
[Name, Date of Birth, Address, Contact Information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Employment status, physical demands of job, and work-related activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[General exercise and activity levels] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medical History (if updated):
[New relevant diagnoses, test results, medication changes, or new referrals since last session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Subjective Update:
[Patient’s report of current symptoms such as dizziness, vertigo, nausea, imbalance, headaches, visual sensitivity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Details of any recent falls or near-falls] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Symptom pattern/provocation – e.g., turning in bed, looking up/down, walking in crowds] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Patient-reported changes since last session – improvement, worsening, new symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Adherence to HEP – frequency, ease/difficulty] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Lifestyle or activity changes – return to driving, work, exercise, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Patient Goals:
[Ongoing or revised short- and long-term goals based on progress and symptom response] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.)
Objective:
[Document re-assessment findings as relevant] (Only include components explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.)
- [Positional testing – Dix-Hallpike, Roll Test, etc.]
- [Oculomotor/VOR testing – VOR x1/x2, smooth pursuit, saccades]
- [Balance – Romberg, mCTSIB, single leg stance, foam conditions]
- [Gait assessment – head turns, dual tasking]
- [Motion sensitivity testing]
- [Symptom reproduction/resolution – nystagmus, nausea, disequilibrium]
- [Outcome measures – DHI, ABC, Motion Sensitivity Quotient (repeat if relevant)]
Treatment Provided:
Education:
[Reinforced explanation of vestibular mechanisms, recovery timelines, neuroplasticity, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Hands-on Treatment (if applicable):
[Canalith repositioning or other manual techniques] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Active Therapy / Exercises Performed During Session:
[Gaze stabilisation drills, habituation tasks, dynamic balance retraining, walking with head turns, visual-vestibular tasks, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assessment:
[Updated clinical impression based on current session findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs.)
[Progression toward goals, symptom behavior, tolerance to exercises] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Barriers or concerns – anxiety, poor tolerance/adherence, worsening symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan:
[Continue or revise vestibular rehab approach, including progressions in balance, gaze, or motion tasks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Updated HEP – include specific exercises with sets, reps, frequency] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Next review – e.g., reassess DHI in 2 weeks, clinical progress check-in] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Referrals if warranted – e.g., ENT, neuro-ophthalmology, psychology] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Fall prevention or safety advice if relevant] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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 included 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 out
