Tri-State Medical Center. Patient: Amy Curtis Sex: Female CA: 34 years old PROCEDURE NOTE

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1 SimuCase 2014 Tri-State Medical Center Patient: Amy Curtis 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 Epidural steroid injection Location 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.

2 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 1 st 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

3 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

4 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 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 Phase Closure: Varied at times the open phase dominated. At other times phase closure appeared to be normal. Phase Symmetry: Equal Inflammation: Mild bilateral vocal folds edema Vibratory Periodicity: Normal Anterior/Posterior Compression: Sometimes present Ventricular Fold Symmetry: Symmetric Ventricular Fold Symmetry: Symmetric Secretions: Normal

5 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: 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.

6 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