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Followup Neuropsychological Evaluation Medical Transcription Example

DATE OF EVALUATION:  MM/DD/YYYY

REASON FOR REFERRAL:  The patient is a (XX)-year-old right-handed male who returns at this time for one-year followup neuropsychological evaluation. He was previously felt to have mild cognitive impairment and followup testing was suggested to determine any progression of his cognitive impairment to rule out dementia.

TESTS PERFORMED:
A.  Selected subtests of the Wechsler Adult Intelligence Scale-III and the Wechsler Memory Scale-III.
B.  California Verbal Learning Test-II.
C.  Rey-Osterrieth Complex Figure Test with recall and recognition trials.
D.  Clock drawing.
E.  Boston Naming Test.
F.  Semantic and Phonemic Verbal Fluency Test.
G.  Grooved Pegboard Test.
H.  Beck Depression Inventory and interview.

BRIEF HISTORY:  The patient stated that he thinks his memory is slightly worse than it was 1 year ago when he was previously tested. He continues to be independent in all of his activities of daily living including driving. He feels that his ability to recall people's names and come up with words and conversations has worsened. He said that he cannot do mental arithmetic as well as he used to. He cannot explain things as well. He said that he tends to avoid social situations so he does not have to express himself, but also said that he has always been anxious in social situations. He feels that the problems he is experiencing have made him depressed. He continues to see Dr. Doe for treatment of depression and is on Zoloft. His dose was recently raised to 200 mg per day. He is no longer on Aricept. He continues to drink 4 to 5 glasses of wine most days. He has not had any changes in his medical condition in the last year.

BEHAVIORAL EXAMINATION:  The patient presented as a very pleasant and cooperative man, neatly dressed and groomed, and appearing approximately his age. He answered questions with a normal degree of elaboration and his thought processes were logical, organized, and goal directed. His mood was somewhat anxious and his affect was slightly constricted in range and intensity. During the testing, he appeared to work to the best of his ability. He understood the instructions and the nature and purpose of the examination. The results are felt to accurately reflect his current level of function.

TEST RESULTS:
1.  Attention, Concentration, and Processing Speed:  The patient could repeat 6 digits forwards and 5 backwards, which compares to 7 forwards and 5 backwards last year. Mental arithmetic was done at a slightly less proficient level, decreasing from the 91st percentile to the 75th percentile for his age. His performance on mental arithmetic tests was somewhat inconsistent and he was often heard incorrectly registering the information that was given, suggesting some attentional problems. Measures of visual and motor processing speed were essentially unchanged. The one exception was his performance on a test requiring visual search for target symbols. He made 4 or 5 errors on this particular test, which is a change from last year.
2.  Memory:  His performance on measures of verbal memory improved. Immediate memory for logically related verbal material improved from the 37th to the 75th percentile, with a similar improvement in delayed recall and retention. Similarly, he demonstrated slight improvement on a word list learning test. These improvements were seen on measures of immediate recall, delayed recall, and recognition memory. In contrast, he showed a slight decline on measure of visual memory, apparent both on immediate recall and delayed recall. Visual recognition memory remained unchanged, in the average range.
3.  Language:  Confrontational naming decreased slightly from a score of 60/60 on the Boston Naming Test to 56/60. Performance on measures of both phonemic and semantic verbal fluency also declined slightly, but remained well within the average range for his age and education.
4.  Visual spatial:  His ability to put together colored blocks to match a model was essentially unchanged. Copy of a complex figure was unchanged. His clock drawing was intact. There was a slight decline on a measure of attention to visual detail.
5.  Motor:  Fine motor speed and dexterity were essentially unchanged bilaterally.
6.  Problem solving, Reasoning, and Executive Functions:  His performance on the Trail Making Test Part B, which involves complex visual or motor tracking and mental flexibility was unchanged at the 54th percentile for his age and education. Verbal abstract concept formation was also unchanged, in the superior range. As mentioned, his clock drawing was good and showed normal spatial planning and conceptualization. His copy of a complex figure was adequately organized and planned.
7.  Emotional:  On the Beck Depression Inventory, he obtained a score of 15, which is in the mildly depressed range. He continues to have problems with self-esteem, indecisiveness, fatigue, poor concentration, and decreased interest. These symptoms were endorsed at a mild level. In the interview, he talked about some degree of social isolation. He moved here for a job and has given up some close friendships that he had on the west coast. He does have several acquaintances, but does not have a close circle of friends like he used to. This continues to be the source of some dysphoria for him.

EVALUATION CONCLUSIONS:  Neuropsychological reevaluation showed improvement on measures of verbal memory, but mild decline on measures of language and visual spatial skills including visual memory. None of the scores fell into the frankly impaired range, but rather showed declines from above average or superior levels to average levels in most cases. It is not clear whether these scores reflect true brain-related changes or simply chance of variations or regression to the mean. Because his memory test scores improved, the likelihood of underlying Alzheimer disease is negligible. However, there may have been some increase in cerebrovascular disease causing the focal changes noted on testing. He said that he had an MRI of the brain in the last year, but those results are not available at this time. The depression may also cause some fluctuations in cognition, both on a day-to-day basis and on formal testing.

DIAGNOSTIC IMPRESSION:
1.  Cognitive disorder, not otherwise specified.
2.  Adjustment disorder with depressed mood.

RECOMMENDATIONS:  The patient should continue to have treatment for the depression. He may need to be encouraged to develop friendships. Retesting should be done in 1 year, given the evidence of changes in specific cognitive skills. He has made an appointment for approximately 1 year from now.

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