Neuropsychological Evaluation Report

NEUROPSYCHOLOGICAL EVALUATION REPORT

1. Patient referred for neuropsychological evaluation to identify the nature and extent of any neurocognitive deficits related to a possible traumatic brain injury as a result of a motor vehicle accident that occurred in June of 2008.
2. Assist in determining further rehabilitation and disposition needs.

1. Record Review – xxxx physician admission summary
2. Clinical Interview
3. Wechsler Adult Intelligence Scale – III (WAIS-III)
4. Selected subtests of the Wechsler Memory Scale – III (WMS-III)
5. California Verbal Learning Test – II (CVLT-II)
6. Word Memory Test
7. Letter Fluency Test
8. Animal Fluency Test
9. Trail Making Test
10. Wisconsin Card Sorting Test
11. Grooved Pegboard Test
12. Finger Tapping Test
13. Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) – short form

BACKGROUND HISTORY AND CHIEF COMPLAINT

The patient is a 38 year-old, married, right handed, Caucasian male who was seen in consultation for a neuropsychological evaluation to identify the nature and extent of any neurocognitive deficits related to a possible traumatic brain injury secondary to aMVA in June of 2008. Thephysician admission summarywas available for review. Additional history was obtained from an interview with the patient on the day of testing. Briefly, on 06/07/08 the patient was an unrestrained driver of a single car MVA. He was ejected from the vehicle and was subsequently run over by another vehicle. He was found unresponsive at the scene. GCS on admission to the ER was 14. He required resuscitation from hemorrhagic shock and hypotension. He suffered multiple injuries including an open pelvic fracture, right inferior rami fracture, left spine TP fracture (L2-4), sternal fracture, T12 burst fracture, bilateral rib fractures, small right pneumothorax, right hemothorax, pulmonary contusions, ascending colon pneumatosis, and mesenteric hematomas. He underwent multiple surgical procedures for management of his injuries and had multiple infections during his hospitalization. The patient also reported that he was on heavily sedating medications for pain throughout his hospital stay. As a result, he reportedly had prominent memory and concentration problems and there was concern for post-concussive syndrome. He was hospitalized at xxxxxxx for about 29 days and was transferred to xxxxx on 07/04/08. He participated in inpatient rehabilitation for about 3 weeks and was discharged home with continued outpatient rehabilitation interventions that are continuing at present.

The patient reported that he remembered “shooting across the highway” prior to his accident, but is not clear on exactly what happened. His first recall post-accident was being hospitalized at xxxxx. Currently, he continues to have problems with ambulation related to his spinal cord injury and hip/pelvic fractures. He is able to ambulate independently, but uses a walker for moderate distances and a wheelchair for longer distances. He has regained fully functioning of his upper extremities. He complained of lingering back pain and is prescribed medications for pain (albeit decreased from the multiple narcotics he was taking previously). Cognitively, the patient reported that he has been experiencing some short term memory and concentration problems dating back to a previous motor vehicle accident that occurred in 1995. The patient believes that his memory and concentration problems noted during his hospitalization were more related to his sedating pain medications. Functionally, the patient reports that he is independent in his daily activities. He has not yet resumed driving. Emotionally, he is reportedly stable and “mostly positive.” He described some “down days,” but this was not viewed as being significantly problematic. Current medications include Effexor, Seroquel, Hydrocodone, and Neurontin. He reported a previous history of heavy alcohol use, but denied any alcohol use since his accident. He does not smoke cigarettes, but does use snuff.

Past medical history is significant for previous injuries secondary to a previous motor vehicle accident in 1995. No records related to this accident were available. According to the patient, he was T-boned by a vehicle and was subsequently pinned in his car requiring extraction. He had limited recall of the details of this accident, but stated that his heart stopped twice en route to the hospital. He was hospitalized for approximately two days, but had difficulties for 6 weeks post-accident. He continues to report short term memory and concentration problems that have lingered since this accident. Additional medical history is significant for 3 previous shoulder surgeries.

The patient currently lives with his wife of 21 years in xxxxx. They have two children (ages 20 and 16). The 16 year old daughter and the patient’s mother-in-law live with the patient and his wife. The patient completed high school and went on to receive technical school training in aero technician work. He has worked as an aircraft mechanic for 18 years. He has been on medical leave and short term disability since his accident. He has no plans for return to work as of yet, but his short term disability runs out in December. He is doing some computer work for his wife’s non-profit organization.

BEHAVIORAL OBSERVATIONS AND MENTAL STATUS EXAM

The patient arrived on time for his appointment and was unaccompanied. He was casually dressed and groomed, alert, oriented, and interactive. A wheelchair was used for mobility. Demeanor was friendly and cooperative, and he was open to examination and comfortable throughout the evaluation process. Language functions were grossly intact for expressive and receptive modalities. Thought processes were clear and goal-directed with content of thought appropriate to the situation. Mood was euthymic with a normal affective range. Observation of upper extremity motor behavior revealed no obvious difficulty or asymmetry. No obvious tactile sensory loss was noted and no auditory or visual difficulties impacted test administration. Cooperation and motivation were appropriate. Insight, awareness, and judgment were appropriate.

TEST RESULTS

Intellectual Functioning: Intellectual performances were average overall with no significant discrepancies noted between verbal and nonverbal abilities (FSIQ = 97; VIQ = 98; PIQ = 94). However, further examination of index and subtest scores revealed mild relative weaknesses on tasks of verbal working memory and visual information processing abilities (low average relative to average or better performances across other more pure measures of intellectual functioning). This weakness is mild in nature, but was notably consistent.

Attention/Concentration: As noted above, verbal working memory and visual information processing speeds were low average on the WAIS-III. Specifically, simple verbal attention span fell within the low average range as did performance on a verbal working memory task (Letter-Number Sequencing). Visual information processing and coding was low average while symbol search and cancellation was average to low average. Visual block span was low average in the forward direction, but average on reverse. Visual sequencing ability on the Trail Making Test was impaired under both a simple numerical sequencing condition and under a more complex condition requiring set-shifting.

Memory Functions: Immediate recall of verbal narrative information was in the high average range with average range delayed recall (86% retention). Acquisition of a 16-item unrelated word list was average overall with good learning noted across multiple presentations (items recalled per trial: 4-8-12-11-13). Recall was average after a short and long delay. He was able to recall 11/16 words spontaneously on both the short and long delay trials. His recognition/discrimination performance also was average, with 15/16 target items correctly identified, but 3 false positive errors were noted. Immediate recall of abstract visual designs was high average. Delayed recall was average with 80% of the previously learned material recalled. Recognition/discrimination performance was average with 4 errors noted on 48 trials.

Performance on a simplistic measure designed to assess effort and motivation was appropriate.

Language Functions: Conversational speech was grossly intact as was auditory comprehension. Generative verbal fluency was mildly impaired for letter based priming with variable performance noted across three trials (raw scores: 5-13-10). Generative fluency was average for category based priming.

Visual Spatial Abilities: Visual spatial abilities on the WAIS-III were average for visual spatial construction, visual analytic reasoning, and visual attention to detail. Visual information processing abilities were in the low average range.

Problem-Solving and Executive Functioning: Performance on a task of novel problem solving and concept formation (WCST) was average overall with all six categories achieved. He grasped the demands of this task quickly, but exhibited mild difficulty in maintaining task requirements – two loss of set errors and some mild perseverative tendencies. As described above, performances on the Trail Making Test were impaired in terms of speed under both a simple numerical sequencing condition and a more complex condition requiring set-shifting. Generative verbal fluency performances were mixed with variable and moderately impaired performance noted for letter based priming and average performance noted for category based priming.

Motor/Sensory Functioning: Fine finger dexterity and finger oscillation speeds were average with no significant lateralizing signs noted. Gross tactile sensation was intact and no obvious visual or auditory difficulties were encountered.

Emotional/Personality Functioning: Personality assessment was completed via a short form of the MMPI-2. The resultant profile is reflective of mild endorsement of depressive symptomatology along with a tendency for social isolation and underlying somatic concerns. Patients with similar profiles tend to present as being damaged in some way and this is coupled with increased negative self consciousness and a tendency to withdraw from previous roles. Given his medical history, this is not necessarily unexpected, but the noted social withdrawal and underlying pessimism and dysphoria may reflect some subtle chronic tendencies in this regard that were heightened by his current physical and functional limitations. All told, this likely reflects mild adjustment difficulties related to his recent injuries and subsequent lifestyle changes.

SUMMARY AND IMPRESSIONS

This 38 year-old, married, right handed, Caucasian male was seen for a neuropsychological evaluation to identify the nature and extent of any neurocognitive deficits related to a possible traumatic brain injury subsequent to his MVA and to assist in determining further rehabilitation and disposition needs. Test results and history are reflective of probable average premorbid intellectual abilities. Relative to this premorbid estimation, neuropsychological test results identified variable performances on attentional tasks and some mild executive and processing deficits. These difficulties were noted in the context of normal range (average range or above) performances in new learning and memory, basic verbal and visual spatial reasoning abilities, language functions, and other attention/concentration tasks. As such, the presenting deficits likely reflect either subtle residual processing deficits related to his recent traumatic brain injury or possibly a more chronic pattern of attentional deficits related to a previous traumatic brain injury. Sedating medications may be complicating the picture to some degree given the variability seen in attentional and executive abilities, but the presence of an underlying mild traumatic brain injury cannot be ruled out. It is expected that these difficulties will improve over time, particularly if his medications can eventually be modified to reduce the potential for sedation and related attentional problems. Some higher level SLP interventions might be considered if the patient reports functional difficulties in day-to-day activitiesor if concerns are raised regarding return to work ability, but at this point these difficulties have not reportedly been problematic.

Diagnosis: Traumatic Brain Injury (854.0)

RECOMMENDATIONS

1. Consideration of reducing his sedating medications as his medical conditions allow might prove beneficial in improving the noted difficulties in attention/concentration and information processing.
2. Some higher level SLP interventions might be considered if the patient reports functional difficulties in day-to-day activities or if concerns are raised regarding return to work ability, but at this point these difficulties have not reportedly been problematic.

Preliminary test results and recommendations were discussed with the patient upon completion of testing. He was open to the feedback and seemed appreciative of the results. He agreed to contact the undersigned if he desired an additional follow up session to include his spouse. Questions were addressed as appropriate with medical issues referred back to his medical providers.

Thank you for this very interesting referral. I hope this evaluation is helpful. Please feel free to call if there are any questions.

______Date: Time:

XXXXX

Licensed Psychologist

Board Certified Clinical Neuropsychologist