Neurology case study

CONSULTATION

CHIEF COMPLAINT

Left hemiparesis.

PERTINENT HISTORY

Apparently, this patient has an extensive past history of alcohol abuse but claims that he abruptly discontinued alcohol intake approximately 12 years ago.  He had the acute onset of left hemiparesis.  Currently this problem has apparently been quite responsive to rehabilitation, with the patient’s primary physical residual being upper extremity weakness.  Patient reports that he is within normal limits in terms of his gait ability at the present time.

The patient’s neurorehabilitation program has apparently been successful as planned.  A psychological consult was requested in order to assist in discharge planning issues — particularly in identifying the patient’s ability to return to his employer.

OBSERVATIONS AND TEST DATA

The patient was interviewed and examined on an exercise mat within the physical therapy area.  The environment was relatively distracting for the patient.  He was in mild discomfort, claiming that his “back hurt.”  Otherwise, the patient appeared to be alert and was able to articulate his recent and past history for me in a fairly coherent fashion.

The patient’s speech is marked by some slurring as he speaks more quickly.  There is also a flat quality (monotone quality) to his speech.  Content of his speech is appropriate.  No evidence of tangential or circumlocutory speech was displayed.

The patient was able to count backwards from 20, albeit his performance was very slow.  The patient was able to recite the alphabet without difficulty — again, slowly.  His recollection for long-term history and events was unimpaired.  Short-term memory was impaired.  Patient was able to recall 1 object of 3 in 3 minutes.

The patient’s recall of the past 5 presidents was excellent.  His orientation was x4.

The patient’s insight and judgment appear to be poor.  He offered little insight into the need for careful review of his mental status prior to returning to work, claiming that since he had a chauffeur, there would be no difficulty.  He also claimed that since he was in management, there would be no difficulty, failing to recognize that a management position of the sort that he described would require excellent mental status.  It is difficult to determine whether the patient’s poor judgment and insight represent some preexisting or premorbid tendency.  Obviously, further evaluation would be necessary.

CONCLUSIONS AND IMPRESSION

To conclude, this 62-year-old victim of cerebrovascular accident with resulting left hemiparesis was recently evaluated.  On mental status evaluation, reduced insight and judgment and
short-term memory were displayed.  Some evidence of articulation difficulty in speech was also displayed.  For example, in
45 seconds the patient was able to produce only 5 words starting with the letter “f.”  A normal result for an individual of his age would be approximately 15 words.  At the present time, it is recommended that further formal psychometric testing is indicated.  We will try to complete as much testing as possible tomorrow in the a.m. prior to the patient’s discharge.  Whatever remaining assessment needs to be conducted will be arranged on an outpatient basis.

Thank you for this referral.  As always, please contact me if I might be of further assistance.

FOOTNOTE

Line 17 (Page 1).  The dictated dash was changed to a comma for proper punctuation.

Line 29 (Page 1).  The phrase orientation x4 means orientation to person, place, time, and future plans.

Line 31 (Page 1).  Appears was changed to appear for correct subject-verb agreement.

Line 35 (Page 1).  Represents was changed to represent for correct subject-verb agreement.

Lines 1-2 (Page 1).  CVA was translated in the Impression for clarity.

Line 6 (Page 1).  The dictated paragraph was not introduced.