BPPV Evaluation Form

MGold

3 Posts
 
Posted - 02/20/2006 :  14:32:03  Show Profile  Reply with Quote
Just wondering if anyone out there had a good evaluation form for evaluating an individual with a vestibular disorder? I have a patient later on this week that is suppose to have BPPV. Our clinic doesn't have a form so I want to develop one. Thanks

georgeu

6 Posts
 
Posted - 02/20/2006 :  15:55:14  Show Profile  Reply with Quote
Here is an example of a SOAP note for a vestibular eval that I have on MS Word file. I simply get the required info and fill in later on the computer. Hope this helps.

BPPV EVAL EXAMPLE
S: Patient is a R handed female who reports insidious onset of sx beginning about 3 months ago. States 1st noticed her sx when she was lying in her bed and turned her head. States her condition has not improved since onset. States has had various tests performed and was diagnosed with BPPV Symptomology: Patient c/o of dizziness and a mild nauseous sensation with positional changes. States her sx would usually last no longer than about 3 seconds. Reports cervical rotation to the R is usually worse. Denies any pain, vision or hearing problems Psychosocial: Pt performs an office job. Reports increase sx/difficulty with getting in/out of bed, rolling in bed, bending down and getting back up, performing sit ups and scanning her environment quickly. C/o of increase sx with watching trains and other objects in motion PMH: sinuses, hypothyroid, heart palpitations, acid reflux, gall bladder surgery, appendectomy, hysterectomy Medications: atenolol, nexium, K+, water pill, lovoxol
O: Observation: mod endomorph, R shoulder lower than L, increase lumbar lordosis Shoulder Girdle AROM: WNL FWD & BWD circles GH AROM: WNL B GH flexion and abduction
Cervcial AROM Resistance
Flexion 75° mild sx coming back up 5/5
Extension 65° mild sx coming back 5/5
Side Bend R 55° 5/5
Side Bend L 55° 5/5
Rotation L 75° 5/5
Rotation R 75° 5/5

Eye-Head Movement Results (normal, abnormal, blurred vision, dizziness…..)
Smooth Pursuit WNL
Scanning WNL
Saccades WNL
VOR- Head moving, stationary object WNL
VOR- Head moving, object moving in-phase WNL
VOR- Head moving, object moving out-of-phase WNL
Visual Fields R peripheral visual field slightly deviated vs. L
Postural Control: SOT: 1) firm surface, eyes open- WNL (able to stand > 1 min without dev), 2) firm surface, eyes closed WNL (able to stand > 1 min but reports feeling fairly unsteady) 3) compliant surface, eyes open WNL (able to stand > 1 min but displays min sway) 4) complaint surface, eyes closed WNL (able to stand 1 min but displays mod sway) Sharpened Rhomberg: 30secs WNL, eyes closed 8 secs before LOB and c/o of mild dizziness and nausea Tandem Walking (25ft): WNL Functional Reach: WNL, Walking with Saccades Vertical and Horizontal: WNL Balance Strategies Used: utilizes hip and ankle strategies Special Tests: Hallpike-Dix Test + R (nystagmus < 30secs), Sidelying Test + with head rotated L and trunk SB R Rx Today/Patient Education: Patient educated on BPPV. Patient received treatment for BPPV R consisting of Epley’s technique. After treatment patient instructed to keep head upright even during sleep for 48 hours and then not to sleep on affected ear until follow-up assessment 1 week later.
A: Patient displays signs and sx consistent of BPPV R. Patient also displays increase reliance on vision for balance suggesting decrease somatosensory and vestibular systems as well. Goals (2-4) wks: 1) patient reports no episode of dizziness and nauseous sensation with position changes 2) patient independent with HEP and management of condition
P: Patient to be seen 1-2 x wk for 2-4 wks for BPPV treatment strategies. Thank you for your referral.

MGold

3 Posts
 
Posted - 02/20/2006 :  20:58:48  Show Profile  Reply with Quote
Thanks for the example. It will be real helpful.