DATE OF CONSULTATION: MM/DD/YYYY
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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