DATE OF CONSULTATION:
MM/DD/YYYY
REFERRING PHYSICIAN: John Doe , MD
REASON FOR CONSULTATION:
To evaluate the patient's current cognitive and emotional function
following central nervous system compromise.
DIAGNOSIS ON PRESENTATION:
Stroke.
HISTORY OF PRESENT ILLNESS:
The patient is a (XX)-year-old gentleman who was transferred from an
outside hospital with right-sided weakness and aphasia. The patient reportedly had a nonhemorrhagic
CVA. The patient was also noted to have
a right homonymous hemianopsia to confrontation with a left gaze preference and
right central facial weakness along with right hemiplegia. The patient also had increased reflexes on
the right compared to the left and aggressive upgoing plantar response. The patient was noted to have a left carotid
bruit. The patient also had an elevated
blood pressure prior to onset. The
patient was evaluated on the acute floor and then transferred to the
rehabilitation unit for further evaluation and treatment.
PAST MEDICAL HISTORY:
Hypertension, but no significant history of diabetes or cardiologic
abnormalities.
PAST SURGICAL HISTORY:
As noted above.
ALLERGIES: NONE NOTED.
MEDICATIONS UPON ADMISSION:
See chart.
FAMILY MEDICAL HISTORY:
Diabetes.
PAST PSYCHIATRIC HISTORY:
Reportedly unremarkable.
SOCIAL HISTORY: The
patient lives with his wife of 40 years.
They live in an older home with no air conditioning or heat. The patient has a son and daughter who also
live in that area. Educationally, the
patient completed high school. Occupationally,
the patient worked in the (XX). Prior to
this stroke, there was no history of reported disability.
SUBSTANCE ABUSE HISTORY:
Positive for remote tobacco history, but negative for alcohol and
illegal substance use.
EXAMINATION RESULTS:
The patient was alert and oriented to self, but further evaluation of
orientation could not be established at this time secondary to aphasia. Interaction with the examiner was pleasant,
but eye contact was limited secondary to the deficits noted above in the
history. Attention span and processing
was extremely brief. Attention span was
brief partly because the patient appeared fatigued and was also unable to
respond appropriately. Information
processing is substantially impaired as well as memory secondary to severe
language dysfunction, aphasia. No
assessment of apraxia was completed at this time. Please see speech therapy's review. According to the patient's wife, he is
normally a very quiet person with limited expression, but no disability was
noted. Upon review of comprehension, the
patient was inconsistent for one-step commands and following at approximately 50%
for yes or no response type format.
Fluency as well as repetition severely impaired. Verbal processing again was severely
impaired. Further language as well as
cognitive testing would be indicated after the patient demonstrates
considerable improvement from this point forward. Thought process and thought content could not
be fully evaluated at this time. There
was no history of any deficit in this area.
The patient does not appear to be experiencing any overt signs of things
like hallucinations or delusions. Regarding
behavioral activity, the patient is restless at times and does require safety
devices to be in place. The wife
indicates concern about him falling. Regarding
affect and mood, the patient's affective expressions were very limited. The patient's wife has indicated that he does
get frustrated and aggravated with his deficit profile as well as language
impairment. A formal assessment cannot
be evaluated at this time secondary to the level of impairment noted. Regarding vegetative features, according to
the patient's wife, he was very restless upon the acute floor, but since being
on rehab, he has been showing increasing abilities. The patient's appetite has been improving,
but following at approximately 50% of normal.
According to the patient's wife, he has lost weight. Energy level is significantly decreased. He fatigues quickly and naps often. Overall awareness of current deficits cannot
be fully assessed at this time. The
patient does have some recognition of deficits secondary to becoming
frustrated, but it is difficult to say as to what his current level of insight
is. Overall adjustment to the
rehabilitation unit appears adequate, in that he is beginning to show changes
associated with therapies. Also, some of
the vegetative features are beginning to improve, which should also help his
overall adjustment to the rehabilitation process. The patient's wife indicated that overall he
has been cooperative and seems motivated for treatments. She also indicated that he is a person who
normally has significant drive and will provide his best efforts.
IMPRESSION: At this
time, neuropsychological impression is consistent with the effects of a large
middle cerebral artery distribution infarct with associated right hemiplegia as
well as language impairment. There was
an issue of visual fields being deficient. This will be further evaluated as the
patient's language skills improve.
Overall adjustment appears consistent with level of frustration
secondary to deficits that would be expected as part of the recovery process.
Axis I: Cognitive
disorder, not otherwise specified, with associated language impairment as well
as adjustment reaction, not otherwise specified, mild.
Axis II:
Deferred.
Axis III: See history
above including a left middle cerebral artery distribution nonhemorrhagic
stroke.
Axis IV: Current
psychosocial stressors include current level of disability as well as loss of
home in this past year as well as economic change.
Axis V: Current global
assessment of functioning equals approximately 35 secondary to severe
communication deficit, and past year would equal approximately 85 to 90.
RECOMMENDATIONS: At
this time, further intervention by Neuropsychology. Will be working with the patient's wife for
educational purposes, as well as helping her to understand cognitive and
linguistic deficits following this type of stroke.
In addition, the patient will be discussed during neurobehavioral rounds
as appropriate, and finally, followup intervention for cognitive as well as
adjustment issues will be provided on an as-needed basis providing that the
patient is able to tolerate this form of treatment. Neuropsychological assessment will likely not
be able to be completed during the time of the inpatient rehabilitation stay
secondary to language impairment.
However, if the patient demonstrates enough comprehension, then
neuropsychological assessment would be attempted. Thank you for this consultation.
Neuropsych Testing Sample Report
Neuropsych Testing Sample Report
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