procedure note
TRANSCRIPT
Simucase™ 2014
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
Simucase™ 2014
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
Simucase™ 2014
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