Makindo Medical Notes

The patient reports a sensation of unsteadiness and difficulty maintaining balance, which has been present for [duration]. There is no history of falls but the patient feels unsteady when walking. Often this is a psychological anxiety issue and in older patients helped with a frame and home adaptions.

History of Present Illness (HPI)

• The patient describes episodes of feeling unsteady, particularly when standing or walking.
• The unsteadiness is not associated with vertigo or a sensation of the room spinning.
• No recent head trauma or known history of neurological conditions.
• The patient denies hearing loss, visual disturbances, or other significant symptoms.

Clinical Findings

• General Observations: The patient appears well and alert. No acute distress. Normal gait on observation, although unsteadiness is noted during tandem walking.
• Neurological Examination:
  • Cranial nerves: Intact, no abnormalities noted.
  • Motor function: Normal power and tone in all four limbs.
  • Coordination: Mild dysmetria (difficulty with finger-nose test). No past-pointing.
  • Reflexes: Normal and symmetrical.
  • Sensation: Intact to light touch, vibration, and proprioception.
  • Romberg test: Positive (increased sway or loss of balance with eyes closed).
  • Gait: Broad-based gait, with mild unsteadiness when turning.
• Cardiovascular Examination: No signs of postural hypotension, normal heart sounds.
• Ear Examination: Tympanic membranes appear normal, no signs of infection or effusion.

Investigations

• Blood Tests:
  • Full blood count (FBC) – to rule out anaemia.
  • Check and replace low B12 and folate levels and Thyroid function tests
  • Blood glucose levels – to rule out hypoglycaemia or diabetes.
• Imaging:
  • Magnetic resonance imaging (MRI) brain: if concerns of cerebellar or vestibular pathology.
  • Computed tomography (CT) scan of the head may be considered if acute or recent trauma is suspected.
• Other Tests:
  • Vestibular function tests (e.g., caloric testing) if vestibular pathology (e.g., labyrinthitis, Meniere’s disease) is suspected.
  • Electrocardiogram (ECG) if there is concern about cardiac arrhythmias but this is an unlikely cause.
  • Postural blood pressure measurements to assess for orthostatic hypotension.
  • Gait analysis and balance assessments (e.g., Timed Up and Go Test) may be useful if gait abnormalities are a concern.

Management Plan

1. Treat Underlying Cause:
   • If vitamin B12 deficiency is identified, initiate supplementation.
   • If hypothyroidism is present, start levothyroxine therapy.
   • If labyrinthitis, consider vestibular rehabilitation exercises
2. Symptomatic Management:
   • A great deal of this is seen in olders who fall and is anxiety driven
   • A zimmer frame can be transformational and can give confidence and help
   • Refer to a physiotherapist for balance and gait training exercises.
   • Consider referral to occupational therapy for rails and grab bars.
3. Referral to Specialist:
   • Neurologist if suspicion of a neurological disorder (e.g., cerebellar ataxia, multiple sclerosis).
   • ENT if vestibular pathology is suspected, and further vestibular testing is required.