Vestibular Follow Up.

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.