Neuropsychological Evaluation - 4  ( Neurology)
Description:  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory."  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined."  It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging."  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test