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Tri-State Medical Center

Patient: Amy Sex: Female CA: 34 years old

PROCEDURE NOTE

Chief Complaint: “I have pain across the back of my head and in the left side of my neck to my

shoulder.”

Patient is a 34 year old female known to the clinic with the following diagnosis:

Pre-Operative Diagnosis

Cervicalgia

Cervical radiculopathy

Displacement, cervical disc w/o myelopathy

Facet joint pain, cervical

Post-Operative Diagnosis

Cervicalgia

Cervical radiculopathy

Displacement, cervical disc w/o myelopathy

Facet joint pain, cervical

Procedure Location

Epidural steroid injection C7, T1 with catheter to C5

Anesthesia Local

History

Patient complains of “I have pain across the back of my head and in the left side of my neck to my

shoulder.”

Oswestry

Patient’s oswestry score today is 18 out of 54 indicating mild functional impairment.

Medical Necessity/Indications/Pre-Operative Plan

Persistent cervicalgia with cervicogenic headaches, status post motor vehicle accident. Because she has

failed conservative care, I certainly feel it is appropriate to consider injection therapy at this time. I

discussed an empiric trial of epidural steroid injections followed by diagnostic cervical facet joint blocks

in the future should she fail to benefit from one or two epidural injections. To that end, the risks of the

procedure were reviewed including, but not limited to, bleeding, infection, neurological complications,

lack of efficacy, increased pain, dural puncture with headache, paralysis, loss of bowel, bladder, or

sexual function, etc. She does wish to proceed and all questions were answered.

Simucase™ 2014

Patient was examined by me prior to the procedure. Examination of heart, lung and mental status were

all within acceptable limits. The patient has been assessed, examined, and cleared for the planned

procedure and level of anesthesia in an ambulatory surgery center.

Description of Procedure

After obtaining informed consent including discussion of risks, benefits and alternatives, the patient was

brought to the procedure room. The patient was placed in the prone position. Appropriate time out was

called. The area was prepped and draped in usual sterile manner. Utilizing fluoroscopy the target level

was identified and made prominent. The skin and subcutaneous tissues were anesthetized with 1 ml of

1.00% Lidocaine. A 18 gauge, 3.5-inch touhy needle was advanced carefully using an interlaminar

approach with loss of resistance, without any paresthesia into the C-7-T1 epidural space on the 1st

attempt. Needle tip placement was confirmed in AP and lateral views. Aspiration was negative for blood

& CSF.

A 20 gauge catheter without a stylette was advanced to the C5 level without paresthesia. A total of 0.50

ml of Omnipaque contrast was used. Contrast spread was noted in the epidural space centrally and to

the left from C4 to C7 level. No intravascular/intrathecal spread was noted prior to injection of

medication. Subsequently, 1 ml of 0.9% Saline with 60 mg of Kenalog was injected without paresthesia.

The needle with catheter was withdrawn, and the tip of the catheter was intact. The patient tolerated

the procedure well and was transported/observed before being discharged in satisfactory condition.

Post-Operative Plan

Accordingly, the patient did undergo a successful cervical epidural steroid injection under fluoroscopic

guidance after a negative pregnancy test was obtained. She tolerated the procedure well and was

discharged in good condition. She will follow up in three weeks for possible repeat epidural injection.

She will call sooner should any problems arise.

RTC in: 3-4 weeks for ESI-Cervical

Thank you Dr. Larkin MD for allowing me to participate in the care of your patient.

Thomas S. Block MD

Board Certified Anesthesiologist

Board Certified Pain Management Specialist

Board Certified Pain Medicine

Implantation Specialist

This document has been electronically signed by Thomas Block MD at 4:24 PM

CENTER FOR COMMUNICATION DISORDERS

SPEECH-LANGUAGE PATHOLOGY PROGRESS REPORT

SERVICE DATE: NOVEMBER 2013 (8 MONTHS PRIOR TO CURRENT EVALUATION)

SERVICES PROVIDED: SPEECH THERAPY

TOTAL THERAPY TIME: 45 MINUTES

CHANGES SINCE LAST VISIT

Amy attended 4 session of voice therapy. Amy reported her vocal quality has not changed.

SKILLED INTERVENTION

A variety of differential diagnostic assessment tasks were utilized during session.

SHORT TERM GOALS:

1. Complete education regarding simple voice mechanics and be able to answer questions about

voice mechanics with 80% accuracy and minimal cues. Patient educated regarding simple voice

mechanics. Patient exhibited good understanding of the information presented and was able to

answer question regarding the information presented with 70% accuracy with moderate cues.

2. Perform relaxation exercises promoting optimal voice production with 80% accuracy with

minimal cues. Did not address.

3. Perform low abdominal/diaphragmatic breathing exercises as optimal support for voice

production with 80% accuracy and minimal cues. Patient able to perform exercises to 70%

accuracy with moderate cues.

4. Perform labial trill exercises in a sustained fashion with pitch glides with 90% accuracy and

minimal cues. Did not address.

5. Identify and utilize optimal pitch, volume, resonant quality and effort pattern during structured

speech activities with 80% accuracy and minimal cues. Did not address.

IMPRESSIONS: Suspect patient has laryngeal dystonia and may benefit from medial management prior to

pursuing additional voice therapy.

PLAN

-refer back to ENT for medical management

-may benefit from voice therapy after medical management

Virginia Goldbloom, CCC-SLP

Speech-Language Pathologist

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MEDICAL INSTITUTE

VIDEOLARYNGOSCOPY REPORT

Service Date: July 2013 (1 year prior to this virtual evaluation)

Referring Provider: Joe Larkin, MD

Reason for Referral: Dysphonia

Medical History

Dysphonia

Anxiety

Depression

MVA

Neck pain

Alopecia

Patient Complaint

One year history of significant changes in vocal quality around the time of a URI. Pt. with history of MVA

with neck injury prior to vocal changes. She describes her voice as very breathy and feels as if air is

leaking out of her nose and mouth when she is trying to speak. She notes her voice sounds normal

when she coughs, sneezes, and laughs.

Laryngeal Exam Details

Patient Instruction The purpose and description of the examination were provided to patient. The patient was able to follow directions and cooperate.

Endoscope Used: Chip tip

Topical Anesthetic: Lidocaine/Afrin to right and left nostrils

Left vocal fold edge: smooth Right vocal fold edge: smooth

Left Amplitude: Normal Right Amplitude: Normal

Left Mucosal Wave: Normal Right Mucosal Wave: Normal

Left Vibratory Behavior: Always fully present Right Vibratory Behavior: Always fully present

Left Abduction/Adduction: Normal Right Abduction/Adduction: Normal

Vertical Level of Approximation: Equal Vibratory Periodicity: Normal

Glottic Closure: Varied; at initiation of a phonation a central gap extending the fold noted but as duration of phonation prolonged closure improved but hyperfunction also noted

Anterior/Posterior Compression: Sometimes present

Phase Closure: Varied at times the open phase dominated. At other times phase closure appeared to be normal.

Ventricular Fold Symmetry: Symmetric

Phase Symmetry: Equal Ventricular Fold Symmetry: Symmetric

Inflammation: Mild bilateral vocal folds edema Secretions: Normal

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Additional Observations: Vocal generally breathy with intermittent episodes of a more normal vocal quality. Breathiness is greater during production of voiced phonemes than voiceless phonemes. Phonation during vegetative activities sounds normal.

Analysis: After application of topical anesthesia to the right and left nares and confirmation of

anesthetic effect, the chip tip scope through the right nares to the level of the larygopharynx. On

examination, the true vocal folds appeared to be mobile bilaterally and mildly edematous but free of

discrete lesions. Glottic closure varied. In general, glottis closure appeared to be somewhat incomplete

at the onset of phonation. However, as phonation progressed, A/P and lateral ventricular compression

was observed. Amplitude, mucosal wave and vibratory function appeared to be grossly symmetrical and

intact bilaterally.

Impressions

1. Severe dysphonia (GEROB3A1S3) potentially secondary to muscle tension dysphonia

2. Mild vocal fold edema likely related to tobacco use also noted.

Recommendations/Plan

1. Patient urged to stop smoking

2. Voice evaluation and trial therapy to improve phonation efficiency

3. Return for follow-up after completion of trial voice therapy

____________________________________________________________________________________

Procedure Note: 31579 Videostroboscopy

Indication: Dysphonia. There is a need for detailed evaluation of the working larynx. Physical findings,

laryngeal function, physiology and mucosal pliability need to be assessed. This examination was

performed in conjunction with a speech-language pathologist.

Anesthesia: The nasal cavity and nasopharynx are topically treated with 4% lidocaine blended 1:1 with

4% oxymetazoline for decongestion when flexible transnasal instrumentation is utilized. The

oropharynx w

Description of Technique: The procedure was described in detail and any questions were answered.

The patient was seated comfortably in the examinator chair. The KayPentax 9200/9100 digital

videostroboscopic system is utilized. A KeyPentax digital laryngoscope is introduced atraumatically

through the nose to the level of the larygopharynx. The nasal cavity, nasopharyx, oropharynx,

hypopharynx, larynx, and subglottis are systematically visualized. Gross and fine vocal fold motion is

assessed. Mucosal pliability and mucosal wave is assessed. The patient was asked to alternatively sniff

or inhale and then phonate /i/ to evaluate fine laryngeal motion. The mucosa was evaluated for mass

lesions, inflammation, and other signs of laryngopharyngeal dysfunction. The patient was asked to

phonate a range of utterances at a variety of pitches and volumes. Mucosal wave was evaluated at Fo.

Stroboscopic images were reviewed both in real time and in slow motion after digital capture.

Abnormalities are highlighted below in findings.

Simucase™ 2014

Findings: The voice quality is intermittently breathy and car vary with utterance. She is more breathy

with voiced phonemes than voiceless. Ends of utterances can be dominated by strain. There are islands

of normal voice and she has normal vestigial sounds.

The vocal folds are mobile bilaterally. There is edema of bilateral vocal folds. Glottic closure is adequate

with most phonatory tasks. There is lateral compression at the end of some utterances. Mucosal wave

is full. No mass lesions. No inflammation apart from minor Reinke’s edema. No vocal fold motion

impairment. No pooling of secretions.

Disposition: The patient tolerated the procedure well and was discharged home with typical post

procedural instructions.

Electronically Signed

Steven Gessler, MD

Simucase™ 2014