NEUROPSYCHOLOGICAL EVALUATION REPORT

(CONFIDENTIAL-DO NOT COPY WITHOUT PERMISSION)

NAME: PatientREFERRED BY: Neurologist, M.D.

DATE OF INTERVIEW:DATE OF TESTING:

DATE OF BIRTH: AGE AT EVALUATION: 37 years

HANDEDNESS: RightDATE OF REPORT:

NEUROBEHAVIORAL STATUS EXAMINATION/INTERVIEW:

The following information was obtained through a clinical interview with Mr. Patient as well as from a review of available records.

Reason for Evaluation:

Mr. Patient is a 37-year-old right-handed Hispanic man who was seen as an outpatient upon referral from his neurologist, Dr. Neurologist. Mr. Patient was seen for evaluation of memory loss (780.93) and confusion s/p tumor removal and post-surgical meningitis. This neuropsychological examination was requested in order to assess his current level of functioning, to assist in differential diagnosis and to make treatment recommendations.

Current Complaints/Symptoms:

When asked why he had been referred for this evaluation, Mr. Patient responded that he experiences problems with his memory and with seizures. He reported the seizures began in 1988 after he had a left frontal tumor removed, and experienced subsequent post-surgical meningitis (see Medical History, below). While he reported a history of up to four seizures a day, he stated that a recent change in his medication has decreased his seizures to up to four a month. Mr. Patient reported having trouble with his short-term memory, frequently forgetting recent conversations. He reported that, since his surgery, his processing speed has been slower. Mr. Patient also reported having frequent word-finding problems as well as often having trouble comprehending others. He stated he requires a lot of explanation and rephrasing from others before he can understand their point. Mr. Patient reported no problems with attention, multitasking, problem solving, or visuospatial abilities. He reported trouble with his balance, sometimes tripping over himself and dropping things. He denied tremors or falls not due to seizures. Mr. Patient reported pain in his legs during his postictal state. He denied difficulty with activities of daily living, as he doesn’t drive or cook due to the possibility of a seizure, and doesn’t manage the finances. His girlfriend reportedly helps him manage his medications, and he denied any problems maintaining personal hygiene.

On a questionnaire format, Mr. Patient endorsed the following current symptoms as problematic: balance problems; tremors or shakiness; concentration problems; loss of feeling, tingling, or numbness; difficulty pronouncing words clearly; sensitivity to light; difficulty remembering the right word; being easily distractible; poor concentration for extended periods of time; difficulty reading or writing; difficulty following through with things; personality changes; black-out spells; irritability; restlessness; mood swings; depression; loss of confidence; feelings of guilt; changes in appetite; nightmares; increased suspiciousness of others; and written next to “other,” has a hard time getting his point across.

Past Psychiatric History:

Mr. Patient denied history of inpatient psychiatric hospitalization or outpatient psychotherapy. He denied suicidal ideation, intent, or plan. He denied problems with sleep, appetite, weight changes, and problems with temper/impulse control.

Medical History:

Mr. Patient denied problems with his gestation or birth, and reportedly met developmental milestones appropriately. He reported occasional past alcohol use, on weekends, though stated he was never a regular drinker. He also reported a history of smoking tobacco, but quit in 1998 because his mother died of cancer a year earlier. Mr. Patient reported he neither smokes nor consumes alcohol presently. He denied a history of illicit drug use.

Mr. Patient reported being in an altercation in 1988 that resulted in a gunshot to the head. The bullet grazed his skull, leading to brain imaging, which revealed the presence of a left frontal tumor. He underwent neurosurgery to remove the tumor, and suffered from post-operative meningitis and began having seizures. Mr. Patient reported the seizures were relatively well controlled with a combination of Tegretol and Keppra until approximately two years ago when they increased in frequency following a fall. He reported having up to four seizures a day, sometimes resulting in falling and hitting his head.

According to medical records reviewed (Dr. Neurologist’s note of September 14, 2010), an EEG performed on August 23, 2010 showed slower rhythm in the left frontal area and brief high-voltage bursts of 3-4 Hz slow waves over the left frontal, more abundant when Mr. Patient was drowsy. Dr. Neurologist’s assessment included the following issues as active: Insomnia (780.52); Fatigue (780.79); Epilepsy (345.90); Health Maintenance (V70.0). She also noted that Mr. Patient’s seizures are complex partial seizures with generalization, s/p tumor/post-surgical meningitis and that these seizures have a left frontal focus. During this visit, Dr. Neurologist increased his dosage of Keppra, and Mr. Patient reported that since this appointment, his seizures have decreased in frequency from up to four a day to up to four a month.

Medications and supplements at the time of this evaluation reportedly included Tegretol 200 mg Q6D; Keppra 500 mg Q5D; Prilosec 20 mg QD; valium 2 mg PRN.

Family History:

Family history was reportedly remarkable for Alzheimer’s disease (paternal grandmother, onset estimated in her late 70’s), diabetes (sister and father), stroke (father), cancer (mother, father, and sister), and alcoholism (father).

Academic/Social History:

Mr. Patient reported that both English and Spanish were his first languages learned. He reported graduating high school in Phoenix, Arizona, receiving mostly B’s and C’s until his surgery. After surgery he attended special education classes half-time (subjects included math, spelling, and reading), and never repeated a grade. Currently unemployed since 2008, Mr. Patient reportedly worked in various occupations including electrical work, dairyman, and seven years as a cabinet builder. The latter was his last job, which ended after he had a seizure and fell off a dock station. Mr. Patient moved from Arizona to Albuquerque in February of this year, and reported currently living with his girlfriend and their five month old daughter. He has a seventeen year old son still living in Arizona.

Records Reviewed:

Dr. Neurologist’s report of Mr. Patient’s consultation regarding seizures dated September 14, 2010.

Previous Neuropsychological Testing:

None Available.

NEUROPSYCHOLOGICAL TESTING:

The following measures were administered according to standardized procedures: Clinical Interview; Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV); Test of Premorbid Functioning (TOPF); Hopkins Adult Reading Test (Forms A and B); Word Memory Test (WMT); California Verbal Learning Test, Second Edition (CVLT-II); Brief Visuospatial Memory Test-Revised (BVMT-R); Wisconsin Card Sorting Test (WCST); Neuropsychological Assessment Battery (NAB; Naming subtest); Finger Tapping Test; Hand Dynamometer; Boston Naming Test, Second Edition (BNT-2); Controlled Oral Word Association Test (COWAT; FAS and Animals); Grooved Pegboard; Trail Making Test, Parts A & B; Stroop test; CLOX: An Executive Clock Drawing Task; Beck Depression Inventory, Second Edition (BDI-II); Minnesota Multiphasic Personality Inventory-2nd Edition, Restructured Form (MMPI-2-RF).

Behavioral Observations

Mr. Patient was a right-handed Hispanic man who appeared his stated age of 37 years. He arrived on time for his evaluation, accompanied by his girlfriend, though she left after helping Mr. Patient complete paperwork for his evaluation. He was alert and oriented to person, place, and date/time. He was very casually dressed and appropriately groomed. Eye contact was appropriate. No difficulties with vision or hearing were noted. He was very friendly, easily engaged, and cooperative throughout the interview and evaluation, and had an active interpersonal style. Spontaneous speech was sometimes tangential, but fluent and without articulation or word-finding difficulties. No abnormalities in speech rate, volume, or tone were noted. Thought process was logical with no evidence of referential thinking. No evidence of delusions or hallucinations was present. He reported his recent mood as “not depressed,” but he stated he is sometimes frustrated and in a bad mood for about half a day at a time. A full range of affect was exhibited, which was appropriate to context. He denied current suicidal ideation, intent, or plan. No tremor or tics were noted. He ambulated independently, and by observation only, no motor abnormalities were present. No difficulties with attending to or comprehending test instructions were noted, and he attempted every test item. Overall, the results reported below are considered to be a valid estimate of current neurocognitive functioning.

Test Results

Motivation

Mr. Patient was administered measures sensitive to insufficient effort. His performance suggested Mr. Patient put forth sufficient effort. Furthermore, on clinical measures with embedded validity indicators, there was evidence of sufficient effort. Thus, the following results are considered to be a valid representation of Mr. Patient’s neurocognitive functioning.

Estimate of Premorbid Function

Mr. Patient obtained a standard score of 74 (4th percentile) on the Test of Premorbid Functioning. In conjunction with his demographic information, this would predict a premorbid WAIS-IV FSIQ of 78 (borderline range, with a prediction interval of 60-96). On separate measures of premorbid estimates of intellectual functioning based on word reading ability, Mr. Patient’s estimated full scale IQ was in the average range (27th – 30th percentile).

General Intellectual Ability

Mr. Patient was administered the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) to assess his overall intellectual functioning. Current FSIQ was 67 (extremely low range, 1st percentile), indicating possible decline in overall intellectual abilities. He obtained extremely low composite scores on the Verbal Comprehension index (VCI; SS = 66, 1st percentile) and the Working Memory index (WMI; SS = 60, 0.4th percentile). Mr. Patient’s composite score on the Perceptual Reasoning index was in the borderline range (PRI; SS = 77, 6th percentile). His composite score on the Processing Speed index was in the low average range (PSI; SS = 86, 18th percentile), and represented a relative strength. The General Ability index (GAI), which removes working memory and processing speed from the overall intellectual estimate, was calculated. His GAI was in the extremely low range (SS = 69, 2nd percentile).

Attentional Functions

On measures of attention, Mr. Patient’s performances ranged from average to severely impaired. In terms of his simple attention span capacity, he performed within the moderately to severely impaired range, with digit string repetition (Digits Forward) that fell at the 0.5th percentile (4 digits) for his age on WAIS-IV. With added working memory (the ability to hold information actively in mind to manipulate it mentally) demands, his performances ranged from moderately impaired to moderately/severely impaired (e.g., Digits Backward at 3.5th percentile, 3 digits; Digit Sequencing at 1.5th percentile, 3 digits; Arithmetic ss = 4, 2nd percentile). As noted earlier, his Working Memory Index score on the WAIS-IV was in the extremely low range (SS = 60, 0.4th percentile).

Perceptual-motor processing speed and efficiency was in the moderately impaired range (e.g., Trails A at 0.7th percentile, 62 sec) compared to peers of similar age and education. His performance on a more complex task of mental set-shifting abilities was also in the moderately impaired range (Trails B at 1st percentile, 143 sec) compared to these same norms. Mental processing speed based on speeded word reading was in the mildly to moderately impaired range (Stroop Word-Reading at 3rd percentile). Based on speeded color naming, mental processing speed was at the high end of the moderately impaired range (Stroop Color-Naming at 2nd percentile).

On the WAIS-IV, efficiency in matching and reproduction of symbols associated with numbers was in the mildly impaired range (Coding ss = 6, 9th percentile). Speeded search of symbolic information was in the average range (Symbol Search ss = 9, 37th percentile). As noted above, his WAIS-IV Processing Speed Index score was in the low average range (SS = 86, 18th percentile), and represented a relative strength.

Learning and Memory Functions:

Considering his ability to initially acquire and encode new information (immediate memory), Mr. Patient’s performances were variable, ranging from average to moderately impaired. Learning of a 16-item word list was in the average range (CVLT-II at 55th percentile) across the five learning trials (6, 8, 11, 12, 14). Initial learning, often considered a marker of attention, was in average range (Trial 1 at 31st percentile), inconsistent with most other measures of attention. Learning of location and content of six visual geometric designs was in the moderately impaired range (BVMT-R at 1st percentile) across the three learning trials (4, 5, 7). Immediate recall was not significantly improved with repeated presentation of materials (Trial 1 at 10th percentile, Trial 2 at 1st percentile, and Trial 3 at 2nd percentile).

With respect to his ability to consolidate and retain learned information over time (delayed memory), Mr. Patient’s performances were variable, as well. With regard to auditory memory, he recalled 10 of the 16 items following a delay, which is in the average range (31st percentile). Recognition discrimination based on a yes/no format was also average (50th percentile), with one false positive error and two false negative errors. With regard to visual memory, delayed free recall of the six visual designs was mildly to moderately impaired (4th percentile). He retained 100% of the original information, which is within the expected range (greater than 16th percentile). Using a yes/no recognition format, discriminability was average, with no errors.

Overall, learning, immediate recall, delayed recall, retention, and recognition of verbal material were within the expected range. While recognition of non-verbal material was within the expected range, learning, immediate recall, and delayed recall of non-verbal material was below expectation.

Language Processing

On the WAIS-IV, verbal abstract reasoning (Similarities, ss = 4, 2nd percentile) and expressive vocabulary skills (Vocabulary, ss = 3, 1st percentile) were in the moderately impaired range. General fund of information was at the upper end of the mildly to moderately impaired range (Information, ss = 5, 5th percentile). Thus, as stated above, his Verbal Comprehension Index score was in the extremely low range (SS = 66, 1st percentile). Phonemic-cued fluency was at the upper end of the moderately impaired range (COWAT; FAS raw = 19, 2nd percentile), while semantic fluency was in the average range (COWAT; Animals raw = 19, 32nd percentile). Mr. Patient’s performance on a complex visual confrontation-naming task was moderately impaired (NAB raw = 27, 1st percentile) compared to peers of similar age and education. Performance on a second confrontation-naming task was in the moderately to severely impaired range (BNT-2 raw = 34, 0.3rd percentile) compared to similarly aged and educated peers.

Visuospatial Processing

Basic constructional skills as measured by the ability to copy a demonstrated clock was in the mildly to moderately impaired range (CLOX2 = 12, 4th percentile). On the WAIS-IV, Mr. Patient’s performances on subtests contributing to the Perceptual Reasoning factor were variable. Visual analysis and reconstruction of 2×2 and 3×3 block designs was in the mildly impaired range (Block Design, ss = 6, 9th percentile). Non-verbal abstract reasoning (Matrix Reasoning, ss = 5, 5th percentile) was at the upper end of the mildly to moderately impaired range. Ability to mentally match and rotate figures to form complete designs (Visual Puzzles, ss = 7, 16th percentile) was in the low average range. As noted above, his overall Perceptual Reasoning index score was in the borderline range (SS = 77, 6th percentile).

Executive Functions

Mr. Patient’s performances on tests that measure complex mental abilities such as cognitive flexibility, planning/organization, and set-shifting were below expectation. Ability to spontaneously draw a clock and set the hands to a specific time was within the severely impaired range (CLOX1 = 8, 0.05th percentile), suggestive of significant difficulty with planning and organization of visual material. As previously mentioned, Mr. Patient’s performance on a complex measure of mental set-shifting abilities was in the moderately impaired range (Trails B at 1st percentile, 143 sec). Performance on a task which required inhibition of automatic responses was also moderately impaired (Stroop Color-Word at 0.5th percentile). Nonverbal concept formation/problem solving was evaluated using a measure that emphasizes discrimination of relevant features of non-verbal stimuli across learning trials (WCST). Performance was moderately impaired for the number of categories completed (raw = 0, less than 1st percentile). Number of errors was in the moderately impaired range (i.e., he committed more errors than expected; raw = 101, less than 1st percentile), and number of perseverative errors was also in the moderately impaired range (raw = 66, less than 1st percentile).

Motor Function

Mr. Patient was right-hand dominant. Strength of manual grip (Hand Dynamometer) was in the low average range for his dominant hand (DH = 45.5 Kg, 16th percentile) and in the average range for his non-dominant hand (NDH = 51.5 Kg, 50th percentile). Simple motor speed was in the low average range for his dominant hand (Finger Tapping Test: DH = 50.4 taps, 21st percentile) and average for his non-dominant hand (NDH = 47.6 taps, 27th percentile). Speeded manual dexterity was in the mildly to moderately impaired range for his dominant hand (DH = 85 sec, 4th percentile) and mildly impaired for his non-dominant hand (NDH = 86 sec, 8th percentile). Thus, results were not consistently lateralized, and were fairly variable across measures.

Emotional/Personality Functioning

Mr. Patient completed a self-report inventory pertaining to depression that does not contain a validity scale. On this measure, his endorsement of items was at the upper end of the minimal range (BDI = 13).

Mr. Patient’s responses on a self-report psychodiagnostic measure (MMPI-2-RF) suggest his results are a valid indicator of his current psychological functioning. Mr. Patient’s pattern of responding indicates that he is experiencing significant persecutory ideation, such as others are conspiring against him. He is likely to display increased suspiciousness of others which may lead to interpersonal difficulties. Additionally, Mr. Patient’s responses indicate a significant concern over somatic symptomotology, including gastrointestinal, head pain, neurological, and cognitive symptoms.

Summary/Impressions:

Mr. Patient is a 37-year-old right-handed Hispanic man who was seen as an outpatient upon referral from his neurologist, Dr. Neurologist. Mr. Patient was seen for evaluation of memory loss (780.93) and confusion s/p tumor removal, post-surgical meningitis, and/or complex partial seizures with generalization. This neuropsychological examination was requested in order to assess his current level of functioning, to assist in differential diagnosis and to make treatment recommendations.

Current test results indicate premorbid intellectual abilities to be between the borderline and average ranges. Current overall intellectual functioning was in the extremely low range, with a relative strength in processing speed. Attentional functions, including simple attention, perceptual-motor and mental processing speed, and working memory, were highly variable, ranging from average to severely impaired. Learning, immediate recall, delayed recall, retention, and recognition of verbal material were within the expected range, as was recognition of non-verbal material. However, learning, immediate recall, and delayed recall of non-verbal material was below expectation. Language skills, with the exception of average performance on a semantic fluency task, were below expectation. Visuospatial processing was variable, ranging from mildly/moderately impaired range to low average. Executive functioning, including mental set-shifting, problem-solving, and planning/organization, was far below expectation. Motor skills were not consistently lateralized, and were fairly variable across measures, ranging from mildly/moderately impaired dominant speeded manual dexterity to average non-dominant hand grip strength and simple motor speed. Self-report emotional measures of depressive symptomatology were at the high end of the minimal range. On a self-report psychodiagnostic measure, Mr. Patient reported increased suspiciousness of others and significant concern over somatic symptomotology.

Diagnosis:

Based on clinical history, behavioral observations, and neurocognitive test results, the following diagnostic impressions are made: Mr. Patient was referred for Memory Loss (780.93) s/p tumor removal and post-surgical meningitis. Information gathered during the interview and assessment suggests the following diagnosis is appropriate at this time: Cognitive Disorder, not otherwise specified (294.9)

Recommendations:

Based on the above results, the following recommendations are made for Mr. Patient:

Should Mr. Patient’s application for Social Security Disability Insurance be denied, or if he should become interested in trying to work again in the future, he might wish to contact the Department of Vocational Rehabilitation (505-841-6450) in order to obtain assistance with evaluating and obtaining an appropriate job placement that would take into account his strengths and weaknesses.

At this time, Mr. Patient is not endorsing clinically significant levels of anxiety and depression. Nonetheless, during the clinical interview and interaction with Mr. Patient and his girlfriend, they both reported experiencing frustration that can sometimes strain their relationship. Thus, it may be beneficial for the couple to contact a psychotherapist and engage in couples’ therapy sessions in order to obtain additional support in their endeavors to maximize Mr. Patient’s daily functioning as well as maintain the quality of their relationship.

It is recommended that Mr. Patient continue to be monitored regularly by his neurologist. If his cognitive symptoms worsen, he should return for an updated neuropsychological evaluation. The present evaluation will serve as baseline data for purposes of comparison across time points.

Thank you for this referral. I can be reached at 505-944-5383 with any questions.

___________________________________

Neuropsychologist

Cc: Neurologist, M.D.

Patient, patient

6616 GULTON CT. NE, SUITE 50 ALBUQUERQUE, NM 87109-4452 P 505/944-5383 F 505/299-4740 www.neuropsychnewmexico.com