C J Long
|Charles J. Long Ph.D., ABPN||(901)678-3036 --- (901)678-2821|
|Neuropsychologist||Fax Number: (901)678-2692|
|Name:_________________||Referred By: _________________|
|Test Date:_________________||Date of Injury: _________________|
|DOB:_________________||Report Date: _________________|
|Age:_________________||Request: Neuropsychological Assessment|
|Dominant Hand:_________________||Medication: _________________|
|Occupation:_________________||Marital Status: _________________|
|Neuropsych Tech:_________________||File I.D. No. _________________|
Intellectual assessment with the Wechsler Adult Intelligence Scale - Revised (WAIS-R) reveals that Mr. _______ is currently functioning within the low average range of intelligence, with no significant discrepancy between verbal and performance abilities. At this testing, his scores were: Verbal IQ, 85; Performance IQ, 80; and Full Scale IQ, 82. (The population average IQ ranges from 90-109.) Although scores for most of the subtests were fairly consistent, Mr. _______ demonstrated relative weaknesses on Digit Span (which assesses short-term memory, attention, and concentration), Digit Symbol (which assesses short-term memory, psychomotor speed, and speed of mental operation), and Block Design (which assesses perceptual organization, analysis and synthesis, and abstraction ability).
Memory assessment reveals that Mr. _______ is functioning within the borderline impaired range for short-term memory abilities. Memory consolidation tasks indicated long-term memory abilities in the low average range. Mr. _______ was able to recall only 70% of the material he had learned previously.
Results of a personality evaluation with the Minnesota Multiphasic Personality Inventory (MMPI) are similar to a profile of individuals who are experiencing a great deal of turmoil and may feel angry and hostile because of being trapped in an intolerable situation. They also tend to feel depressed by the loss of positive experiences (job, family, health, etc.) and may experience alternate periods of frustration, aggravation, and indifference. Results of the Cornell Medical Index reveal that Mr. _______ is experiencing a significant amount of emotional distress. Endorsed items relate to depression, anxiety, confusion, irritability, and fear. While completing the Cornell, Mr. _______ stated that it was filled with questions that he wished people would ask, but they never did -- indicating a need to talk about some of the problems dealt with on the questionnaire. It should also be noted that on both the Cornell Medical Index and on the MMPI, Mr. _______ indicated that he often wished he was "dead and away from it all". However, when queried on the subject, he maintained that he had no current plans for suicide.
As a result of the above information gained from a full day of neuropsychological testing and from background information provided by Mr. _______, the following conclusions are made:
(2) The nature of Mr. _______' profile is consistent with residual weaknesses secondary to traumatic brain injury. His greatest deficits were noted on tasks sensitive to vision, sensory functions with the right hand, memory (especially visual memory), slowed speed of processing, and difficulty with processing on complex tasks. All of the above are consistent with generalized cognitive weaknesses which are greater on tasks sensitive to the continuity of the left anterior cerebrum.
(3) Further analysis of the test data indicate several areas of cognitive deficits and cognitive slowing which appear to be directly related to the injuries he received in his May 19, 1989, motor vehicle accident.
(4) The fact that Mr. _______' intellectual testing resulted in impaired scores on the Digit Span, Digit Symbol, and Block Design subtests is consistent with the nature of his injury. In fact, these are precisely the subtests on which you would expect to see impairment. Based on this finding plus Mr. _______' relatively stable performance on the other subtests, it is estimated that Mr. _______' premorbid IQ scores would have been within the average range (i.e., 90 and above). Thus, premorbidly, Mr. _______ is estimated to have been functioning within the average (rather than low average) range of intelligence. Analysis of the overall test findings suggest that his current level of cognitive functioning is 20 to 30 percent below his pre-injury level. This is further augmented by his visual handicap and emotional distress; both of which may possibly be remediated by effective intervention.
(5) In addition to his verbal report and behavior, the absence of a reflexive response to a light shown into Mr. _______' left eye suggests that Mr. _______' reported loss of vision in his left eye most likely results from damage to the optic nerve rather than to the posterior cerebrum.
(6) In addition to the physical and cognitive losses outlined above and the absence of any early rehabilitation attempts, Mr. _______ lost his place of steady employment. The resulting financial problems reportedly make it impossible for him to provide a home for his two sons, his fiancee, and himself; and, for this reason, each family member now must live in a separate location with other relatives. The brain damage and loss of vision in his left eye, coupled with the previously mentioned problems, makes Mr. _______ feel as though he is "no longer a whole person", and he experiences varying degrees of depression, anger, and helplessness. The net result is that, although he does not currently have suicidal plans, he frequently wishes that he were dead.
(2) Mr. _______ needs to have surgery to have a metal plate inserted to replace the missing portion of his skull. Without this, he is in continual danger of further brain damage which could result from even mild blows to his head. Both his emotional adjustment and his employment possibilities are also going to be greatly limited until this problem is rectified.
(3) At this late date, it is doubtful if specific rehabilitative efforts will yield significant results. It is quite likely that earlier intervention would have minimized the emotional distress that he currently experiences. However, vocational assessment and training is indicated. This program can assist Mr. _______ in developing skills for jobs relevant to his location and residual deficits.
On ____________, Mr. _______ was injured in a motor vehicle accident: while he was making a left turn, his vehicle was struck from behind by an 18-wheeler. Mr. _______ received a left temporal-frontal depressed skull fracture and was transported to the ______ Hospital, where he remained in a coma for approximately two weeks. Brain surgery was performed by Dr. ______ ______; as a result of the injury, a portion of Mr. _______' left temporal area skull is missing -- as he has not yet undergone cosmetic surgery to replace the bone. A few days after coming out of the coma, Mr. _______ was released from the hospital. He says that this may partly have been due to his troublesome behavior: he kept pulling out his IV tubes, wanting to leave the hospital and go to _____________. Mr. _______ also speculates that his early release may have been due to the lack of insurance to cover medical expenses.
Mr. _______ has no memory of the accident itself. Retrograde amnesia is approximately two minutes; post-traumatic amnesia is estimated at 14+ days. For approximately four or five months following his release from ______ Hospital, Mr. _______ had periodic seizures (accompanied by bleeding from his left ear and nose); on several occasions the seizures were severe enough that he had to be taken to the Emergency Room at the ______ ______ Hospital in _____ _______. Eventually he was put on medication for this condition.
Mr. _______ reports that, since the accident, he has had no vision in his left eye. For several months after his injury, he states that he had no feeling on the left side of his body; that condition has rectified itself, but he still experiences his left side as being relatively weak. For several months, he also had extreme difficulty with hearing in his left ear; this condition has also improved, but Mr. _______ states that hearing in that ear is still somewhat weaker than in the right ear.
Other problems that continue to plague Mr. _______ are: (1) the absence of bone in the left temporal area of his skull leaves his brain vulnerable to additional injury; and Mr. _______ is therefore afraid of falling, getting hit, etc., and receiving further damage to his brain; (2) this "unprotected area of his brain" plus the loss of vision in his left eye result in his decreased employability; (3) he has continued memory problems (though these have improved with time); (4) he experiences problems with balance (e.g., he constantly feels as though he is "walking downstairs" although he is not, and he feels momentarily off balance when someone pats him on the arm); (5) he gets headaches and experiences ringing and humming in his ears when stressed or worried; (6) he feels depressed and is less patient than he was; as a result, friends and family find him more difficult to get along with; (7) he is more socially isolated now; he doesn't enjoy doing things with friends (especially in public places) because he doesn't feel like a "whole human being" anymore; and (8) he has problems going to sleep and wakes up frequently during the night (often due to nightmares).
Mr. _______ and his fiancee have two sons (ages 4 and 10). Prior to the accident, they all lived together. As a result of his injuries, the medical expenses incurred, and his loss of income, they lost their apartment. They were unable to remain together because he and his fiancee both came from large families with limited living space. For this reason, he had to move in with his family; she moved in with her family; one son was sent to Mr. _______' grandmother; and the other son went to the fiancee's grandmother. Although Mr. _______ and his fiancee still financially support their two sons, the grandmothers are now responsible for the sons' daily care. As a result, the grandmothers are now seriously talking of suing for legal custody of the children. This possibility greatly bothers Mr. _______. He says that, because of his injuries, he has already lost everything except his kids and that, if he lost them also, he would just fall apart and lose all reason for going on with his life.
After graduating from high school, Mr. _______ spent three years in the army. He then obtained a barber's license and ran a barber shop for three years. After that, he was an inspector at a factory in _____ _______ for three years; then after working at a temporary job, he began working at an aluminum siding company two months prior to his accident. Unable to work for approximately 13 months, he lost that job. Mr. _______ reportedly was told that he had too much education to get disability; so he continued looking for employment and finally, in June, 1990, obtained a job as a material handler at _____ Inc. Although he has now been employed there for 19 months, he has only been able to work for about 8 months (due to frequent layoffs). He says that he has been unable to obtain other work because he always fails the physical (due to his lack of vision in the left eye and the missing portion of his left temporal skull). He thought about returning to work as a barber, but this doesn't seem possible because of the lack of vision in his left eye: he's tried cutting his brothers' hair, and it didn't turn out right.
During the entire testing session (which lasted 7 hours) Mr. _______ was friendly and cooperative, and he appeared to answer all questions openly and honestly. Mr. _______ wanted to terminate several of the more difficult tasks which he found especially frustrating; however, with continued reassurance from the examiner, he persisted with the requirements of each of these tasks, and he appeared to give his best effort throughout the testing session.
For the above reasons, it is believed that Mr. _______ performed to the best of his ability during the entire testing and that the test findings represent a valid estimate of his current level of functioning.
Psychomotor: Tapping speed with the left hand was borderline impaired, but right-hand tapping speed fell within the average range. Bilateral performance was in the average range for grip strength and on tests assessing psychomotor speed and eye-hand coordination.
Perceptual-Motor: These tasks required the tracking of numbers, letters, and numbers and letters in alteration. These tasks assess psychomotor speed as well as eye-hand coordination. Mr. _______' performance was moderately impaired when tracking numbers alone and when tracking numbers and letters in alteration.
Integrative: On a complex integrative task, Mr. _______ was required to place differently shaped wooden blocks into their appropriate spaces on a board while blindfolded. This required psychomotor skill as well as tactual and kinesthetic perception. On this task, Mr. _______' performance fell within the severely impaired range. Memory for the shapes of blocks was moderately impaired; memory for their location on the board was mildly impaired.
Language: Basic language functioning as assessed with the Thurstone Word Fluency Test revealed performance that was in the average range. On this task, Mr. _______ was required to generate as many words as possible falling within certain constraints (e.g., "S" words). On the aphasia screening task, performance was also in the average range.
Intellectual: Intellectual assessment with the Wechsler Adult Intelligence Scale - Revised (WAIS-R) revealed that Mr. _______ is currently functioning within the low average range of intelligence, with no significant discrepancy between verbal and performance abilities. At this testing, his scores were 82 to 85. (The population average IQ ranges from 90-109.) Although scores for most of the subtests were fairly consistent, Mr. _______ demonstrated relative weaknesses on Digit Span (which assesses short-term memory, attention, and concentration), Digit Symbol (which assesses short-term memory, psychomotor speed, and speed of mental operation), and Block Design (which assesses perceptual organization, analysis and synthesis, and abstract conceptualization ability).
Memory: Memory assessment reveals that Mr. _______' short-term memory functioning is within the borderline impaired range. Memory consolidation, assessed in a one-hour-delayed recall of previously learned information, reveals long-term memory in the low average range. Mr. _______ was able to recall only 70% of the material he had learned previously.
Personality: Results of the Minnesota Multiphasic Personality Inventory (MMPI) are similar to a profile of individuals who are experiencing a great deal of turmoil and may feel angry and hostile because of being trapped in an intolerable situation. They also tend to feel depressed by the loss of positive experiences (job, family, health, etc.) and may experience alternate periods of frustration, aggravation, and indifference. Individuals with this profile also tend to have feelings of insecurity, inadequacy, and inferiority. Results of the Cornell Medical Index are similar. Endorsed items relate to depression, anxiety, confusion, irritability, and fear. It should also be noted that on both the Cornell Medical Index and on the MMPI, Mr. _______ indicated that he often wished he was "dead and away from it all". However, when questioned, he maintained that he had no plans for suicide.
Thank you for allowing us to evaluate this interesting case. Mr. _______' data will be maintained in our files for your future reference.