Student PT Name: Amber Clees

Physical Therapy Evaluation / Plan of Care Form

Patient Information and Demographics:

Name: Justin O’Dowd (prefers: Justin) Age:76 y/o Gender identification: Male

Date of Service: 12/1/21

Administrative Codes:
PT Diagnosis (ICD-10): R42 Vertigo

Medical Diagnosis (ICD-10): H81.10 BPPV

Current Procedure Units Duration

Terminology (CPT) Billing
Codes
97161 Low Complexity 1 45 minutes
Physical Therapy Evaluation
Manual Therapy 1 8 minutes
Patient Education 0 5 minutes

SUBJECTIVE:

CC / Reason for Referral:

Patient referred to physical therapy for treatment of BPPV. Patient’s chief complaint is dizziness with
head movement.

Onset and Progression of symptoms:

Patient reports first onset of dizziness occurred in February of 2020. He reports being on a wild ride at
Disney World with his grandchildren, we he got off, he felt very dizzy. He then went to a neuro-
otologist while in Florida who diagnosed him with BPPV of the right ear. The neuro-otologist performed
a rolling maneuver on him, and he reported that made him feel better. He then returned to Michigan and
went to the Vestibular Testing center at the University of Michigan for treatment, but dizziness returned
later in the year. He then went to Jack’s PT Services for treatment, but he reports his dizziness
improving very minimally. His treatment there included a rolling maneuver, head-shaking exercises, and
a printed exercise form. This year he reports having very few episodes of dizziness. But in the past few
months, dizziness has been on and off throughout the day, especially after changing head positions. He
reports the dizziness lasting approximately three to five seconds. He went to his family physician and
got a prescription to see a physical therapist specialized in vestibular treatment.

Previous Medical and Surgical History:

Patient reports history of Hypertension, Hemorrhoidectomy, Appendectomy and hernia.

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 Student PT Name: Amber Clees

Current Medications:
Medication Reason this patient is taking Dose and Frequency
Covera Hypertension Unknown
Aspirin CVA and MI prevention Unknown

Level of Activities Prior to Current Onset:

Patient reports not limiting activities due to onset of symptoms. He reports stopping what he is doing for
three to five seconds to wait for the dizziness to subside and then continues what he was doing. Patient is
a retired carpenter. He volunteers in the community at grade schools doing story time with the children
and bringing his dog to the classes. He also has a woodshop in his garage where he makes furniture and
other items that he sells in the local craft fair.

Home /Work/ Other Relevant Environment(s):

Patient lives with wife in a ranch-style home with 3 steps to enter and a railing on the R. There are 3
bedrooms and 1.5 bathrooms. The house primarily consists of wood flooring and some carpeting in the
living room and bedrooms.

Psycho-social / Family Support / Family Responsibilities:

Patient reports having good support from wife who is retired and in good health. He has children and
grandchildren living in the area that are supportive as well.

Relevant Dietary / Elimination Issues:

None stated.

History of falls:
No history of falls.

Client Goals:
Patient’s stated goals are to be able to perform ADLs, be able to play with grandchildren, and go on
walks with his dog without getting dizzy.

OBJECTIVE:

Vital Signs:
Position / Arm used BP Pulse RR Pulse Ox
Sitting 170/90 60 14 98%

Communication, Cognition, Orientation:

Patient is A&Ox4.

Cranial nerves and related systems:

Cranial nerve screen was performed due to possible complication, and all nerves were intact. Pt reports
being deaf and having ringing in his R hear for many years due to a missile explosion close to him while

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 Student PT Name: Amber Clees

in the military. This explosion knocked him unconscious for 3 days and resulted in the deafness and
tinnitus of the R ear. The left ear was not affected.

Oculomotor examination: no spontaneous or gaze-holding nystagmus, smooth pursuits, and saccades

WNL. VOR to slow and fast head movements negative. No dizziness with any vestibular testing
including Dix-Hallpike Maneuver.

Reflexes:
Reflex Right Left Remarks
Ankle jerk 2+ 2+ Normal DTRs throughout
LEs
Quadriceps 2+ 2+
Biceps 2+ 2+ Normal DTRs throughout
UEs
Triceps 2+ 2+
Plantar reflex Normal Normal

ROM, Strength, Tone, Patterned Movement:

ROM: Pt presented with AROM WFL throughout bilat UEs and LEs upon gross AROM screen.

Strength: Pt presented with 5/5 strength throughout bilat UEs and LEs upon gross strength screen.

Muscle Tone: Pt resented with normal muscle tone throughout bilat UEs and LEs.

Movement Patterns: pt presented with normal movement patterns of bilat UEs and LEs.

Co-ordination:
Test Right Left Remarks
Finger to Nose No abnormalities No abnormalities
found found
Heel to Shin No abnormalities No abnormalities
found found

Sensation:
Right Upper Extremity
Light Touch No abnormalities found
Right Lower Extremity
Light Touch No abnormalities found
Left Upper Extremity
No abnormalities found
Left Lower Extremity
No abnormalities found

Bed Mobility and Transfers:

Pt is independent with all bed mobility and transfers upon observation.

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 Student PT Name: Amber Clees

Posture:
Pt presents with slightly rounded shoulders, forward head, and slightly kyphotic posture in sitting and
standing.

Balance:
No balance abnormalities found upon observation and gross balance screen.

Gait/Locomotion:
No gait abnormalities found upon observation during ambulation.

Functional Independence Measure Scores:

Activity Score NA = Not Applicable (does not occur)
Transfers: 7 NT = Not Tested (mention why)
1 = Total Assistance (0-24%)
2 = Maximal Assistance (25% - 49%)
Gait: 7 3 = Moderate Assistance (50% - 74%)
4 = Minimal Assistance (75% - 100%)
5 = Supervision or Set-up (safety concern / takes more than reasonable
time)
Stairs: 7
6 = Modified Independence (assistive device)
7 = Complete Independence
RULE for GAIT (and W/C): distance modifies the scoring as follows:
3 = to get this or higher must go 150 feet or greater
2 = 50 to 149 feet (see household exception)
1 = less than 50 feet
Household Exception rule: Client who can walk 50 feet independently
with or without a device can get a 5
RULE for STEPS:
3 = to get this or higher must go 12 – 14 steps
2 = 4 to 6 (or less than 12)
1 = less than 4 steps
Household Exception rule: Client who do 4 – 6 steps independently
with or without a device can get a 5

Standardized Tests Used. Insert these here unless clearly documented elsewhere:
Test Score Interpretation / Rationale
Dizziness 22/100 Patient scored a 22/100 with most difficulty with functional activities. Patient is
handicap mildly affected by dizziness with functional, emotional, and physical activities.
inventory

Today’s Interventions:
The patient was informed of the process of physical therapy before the exam and pt gave verbal consent
to continue. The pt was informed of examination findings and recommended treatment plan,
interventions, benefits, and any potential risks of PT and then gave consent to treat. The pt was actively

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 Student PT Name: Amber Clees

involved in goal setting. Performed Dix-Hallpike maneuver on patient to treat R posterior canalithiasis.
Pt education was also provided to ensure patient safety and fall prevention.

ASSESMENT:
Patient presents with previous symptoms related to R posterior canalithiasis. Patient experienced a
common mechanism of injury, complaints of vertigo, and occasional dizziness with head movements.
Patient presented with no symptoms or abnormal findings upon today’s visit. Patient is appropriate for
skilled physical therapy to address limitations noted above and to accomplish the patient’s goals.

Precautions: Fall risk due to pt report of dizziness with head movement.

Rehabilitation Prognosis:
Patient has good rehab potential. Patient has complaints of occasional dizziness and recurring symptoms
of R posterior canalithiasis that can likely be treated with physical therapy interventions. Pt is motivated
to get relief of symptoms and not be affected by symptoms in his daily life. Patient also has great
support from wife and family willing to help as needed.

GOALS (to be achieved by discharge in 1-2 visits):

1. Patient reports not having onset of dizziness with head movements in his daily life to improve
efficiency and increase amount of activities in his daily life.
2. Patient will verbalize understanding of when to refer back to physician and/or physical therapy when
symptoms related to vestibular dysfunction occur using the talk-back method.
3. Patient adherent and independent with HEP and self-management techniques to continue to progress
and improve symptoms.

PLAN:
Patient will be seen for a 45-60-minute treatment 1-2x/week for 1-2 weeks or until discharge. Treatment
may include the following: therapeutic exercise, therapeutic activities, neuromuscular reeducation, and
vestibular management techniques. Pt to be reassessed and discharged, if necessary, at next visit.

A referral back to the MD for that hi BP is also

appropriate!

I certify / recertify that the above therapy services are necessary, and I agree with the plan of care above.

__________________________________ __________ __Amber Clees, SPT __________2/2/21__

Physician Name/Signature Date Therapist Name/Signature Date

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 Student PT Name: Amber Clees

H eE ec eP ga
C a b A b C D 2 , 2021 Vie ideos at .HEP. ideo

Total 5

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 Student PT Name: Amber Clees

H eE ec eP ga
C ea ed b A be C ee Dec 2 d, 2021 Vie ideos at .HEP. ideo

Total 2

OR 1 ER ICAL - E IB LAR OC LAR R 20 T e

REFLE C 1 Se
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OR 1 ALKING - E IB LAR OC LAR R 20 T e

REFLE C 1 Se
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V de # VVMCLWPCQ

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 Student PT Name: Amber Clees

1. Write a Discharge Note based on a reasoned discharge criteria – insert this at the end of
your evaluation form.

Patient discharged from physical therapy due to patient’s reports of discontinued symptoms
relating to vestibular dysfunction. Patient presented with minimal symptoms upon initial
evaluation. Patient had prior symptoms relating to R posterior canalithiasis. Patient reports
discontinued symptoms of dizziness with head movements. Patient understands when to refer
back to physician and/or physical therapy if symptoms recur. Patient’s chart will stay open for 30
days and PT will keep in contact with patient to check in on recurrence of symptoms related to
vestibular dysfunction.
Make sure you specifically address each of the goals you established during
evaluation as MET, Partially MET, or NOT MET.

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