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neuro case hostory 2

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neuro case hostory 2

  1. 1. The case studywas conducted ona client withTraumaticBrain Injury,usingdifferent neuro-psychological tools. Case Study Report Neuro-psychologicalAssessment By Abeera Saleem
  2. 2. 1Case Study Neuropsychological Case Study Report: 1. Identifying Information: A 49 years old male patient X is brought by his family with cluster of complaints that are the after-effects of his recent open head injury. He is Civil Engineer and lives in Y city. He has a wife and three children, one daughter and two sons. He has recovered from the head injury but the post-injury symptoms are appearing now which has brought him back for further assessment. 2. Referral Source: Referred by Dr. XY 3. Presenting Complaints: The interview with the patient revealed that the patient is facing many cognitive as well as neuro- physiological problems including headache, confusion, numbness in left side of body etc. He is also experiencing lack of decision making abilities and problem solving which is affecting his daily functioning especially at home and work. He is experiencing problems in speech as well. The control over his body movements is also being affected. All these symptoms are causing stress as well. The patient says: “I have been feeling really stressed since my accident. Soon after accident I had no other problem but the pain due to wound in my head but when that wound had healed I realized that other problems are also there, appearing gradually. My speech is not that fluent. My concentration and decision making abilities seem to be fading. I feel sometimes as if my left side of body is numb. I feel I am losing control over my body. My movements are not that well as they were before. I feel weak. All this not only affects my life at home but also on work”.
  3. 3. 2Case Study 4. Client’s History:  2.4.1. History of Presenting Problems: The presenting problems have been rising after the recent open head injury of the patient. He had an accident two weeks back and fell from his motorbike while the right side of his head struck a pointed metallic rod. This caused severe bleeding. The wound was treated with stitches and the patient felt being recovered from the injury. But the symptoms of after-effects are now causing him to suffer.  2.4.2. Past Psychiatric History: No significant past psychiatric history.  2.4.3. Past Medical History: 1. History of Diabetes, from the past fifteen years. 2. History of Hypertension from the past eight years. 3. History of Heart Disease. Patient had an Eschemic Heart Attack three years back and went through angioplasty, where three valves of the heart were surgically treated by stents.  2.4.4. Family History: Patient has a wife and three children, a daughter and two sons. The patient has good relations with his family members. Patient’s mother has died while father is alive. The patient has a family history of heart disease and hypertension. His wife has hypertension as well. Patient’s mother died because of paralysis.  2.4.5. Marital History: The patient got married at the age of 28 years. It was an arranged marriage. The initial marital relationship was good nut then it was followed by some disputes. But now there is no such tension in his marital relationship.  2.4.6. Drug history: The patient has regularly been taking the following drugs:
  4. 4. 3Case Study 1. Tinormin (for hypertension) 2. Inderal (for angina and hypertension) 3. Loprine (blood thinner) 4. Insulin injection (for Diabetes)  2.4.7. Social History: The interview with the patient revealed that the patient has a large social circle. The family also told that the patient has good terms with relatives as well as colleagues, friends, neighbors etc.  2.4.8. Premorbid Personality: Before the presenting problems started to appear, the patient was very outgoing, responsible and humorous person. On the other hand he was quite aggressive as well. 5. Mental Status Examination: The patient is a middle aged man, has tall height and seems to be little overweight. He was dressed appropriately and there were no signs of self-neglect. Rapport with patient was easily established and his attitude towards the examiner was positive and cooperative. The orientation to person, time and place was normal. His mood was depressed and despaired. While affect seemed to be constricted. His speech was not fluent and had many pauses and utterances. However the content of speech was relevant. Perception was appropriate. There were no bizarre thoughts. His cognitive functioning was disturbed especially his problem solving abilities and concentration. However, his memory was fine. His thinking was more abstract and he had insight. The information provided by him was apparently reliable. 6. Neuro-psychological Assessment: The client was assessed using:  Clinical Interview  Clinical Observation  Mini-Mental Status Exam (MMSE):
  5. 5. 4Case Study The MMSE is a series of questions and tests, each of which scores points if answered correctly. If every answer is correct, a maximum score of 30 points is possible. The MMSE tests a number of different mental abilities, including a person's memory, attention and language.  CT Scan: Computerized tomography (CT scan) — also called CT — combines a series of X-ray views taken from many different angles and computer processing to create cross- sectional images of the bones and soft tissues inside your body. The resulting images can be compared to looking down at single slices of bread from a loaf.  Bender-Gestalt Test (BGT): The Bender Visual Motor Gestalt Test, or simply the Bender-Gestalt test, is a psychological test first developed by child neuro-psychiatrist Lauretta Bender. The test is used to evaluate "visual-motor maturity", to screen for developmental disorders, or to assess neurological function or brain damage. The original test consists of nine figures, each on its own 3 × 5 card. The subject is shown each figure and asked to copy it onto a piece of blank paper. The test typically takes 7–10 minutes, after which the results are scored based on accuracy and other characteristics.  MS Aphasia Screening Test: The Mississippi Aphasia Screening Test (MAST) was developed as a brief, repeatable screening measure for individuals with severely impaired communication/language skills. Such a brief measure may be advantageous for individuals with severe language impairments who may be frustrated and stressed during lengthy testing sessions. The MAST was designed to be used for serial assessments to detect changes in language abilities over time. The current form has nine subtests that range from 1 to 10 items per subscale. The MAST can be administered in 5 to 15 minutes. Finally, it has been utilized with a wide variety of
  6. 6. 5Case Study patient populations including traumatic brain injury, stroke, epilepsy, anoxia, dementia, and various encephalo-pathies.  STROOP Neuro-psychological Screening Test: The Stroop Color and Word Test were designed to differentiate between individuals who are non-brain damaged and individuals with brain damage. This brief five minute test is applicable for those between the ages of 15 and 90. This test remains a standard measure in neuropsychological assessment. It assesses cognitive processing and provides valuable diagnostic information on brain dysfunction, cognition, and psychopathology. The Stroop Color and Word Test consists of a Word Page with color words printed in black ink, a Color Page with ‘Xs’ printed in color, and a color-Word Page with words from the first page printed in colors from the second page (the color and the word do not match). The respondent goes down each sheet reading words or naming the ink colors as quickly as possible within a time limit. The test yields three scores based on the number of items completed on each of the three stimulus sheets. An Interference score, which is useful in determining the individual’s cognitive flexibility, creativity, and reaction to cognitive pressures also can be calculated. A stopwatch is required to administer each test. 6.1. Test Results and Interpretation:  1. MMSE: Result: Total score of the client was 25 out of a maximum 30 scores, with full scores on the items regarding orientation to time, orientation to place, registration, recall, language, complex commands etc. but scored significantly low (1 out of 5) in items related to attention or concentration. Interpretation: From the results it can be interpreted that the client does not have any cognitive impairment but the score of 25 is considered as questionable or just lying at threshold. All other cognitive domains seem to be normal except the concentration or attention domain which is significantly impaired.
  7. 7. 6Case Study  Head CT Scan: The client’s presenting complaints like problems in cognitive functions, decision making, concentration, motor functions on left side of body were indicators that the client’s frontal lobe might have been damaged in the head injury. Moreover the somato-sensory complaints like numbness of left side of body were indicators of damage to parietal lobe. For the confirmation, client’s head CT scan was performed by Dr. Asad Ali, FCPS, Radiology, Shifa International Hospital, Rawalpindi. Result: The CT scan revealed that there was approximately 74 x 7 mm subdural hemorrhage in right Fronto-Parietal lobe with asymmetrically small right lateral ventricle suggesting mild mass effect. However no midline shift was present. Interpretation: The hemorrhage in fronto-parietal lobe indicate the underlying reasons behind client’s lack of concentration, confusion, problem solving abilities, poor motor functioning and numbness of left side of body. When it has been confirmed that the fronto-parietal area is damaged, then other related domains should also be assessed that are related to these brain areas as well as related to right hemispheric damage as a whole.  Bender Gestalt Test (BGT): As the parietal region is also affected and other then somato-sensory and perceptual functions it is also concerned with integrating sensory input, primarily with the visual system, so the visual domain of the client is was also needed to be assessed. For that purpose BGT was applied. Result: The client’s score on BGT was 4. Errors committed were simplification, perseveration, closure difficulty and retrogression. Interpretation: The score of 4 is a borderline score. This means that though the client does not have severe brain damage but still the visuo-motor and perceptual deficiency exists.
  8. 8. 7Case Study  MS Aphasia Screening Test: The clients presenting problems show that he is experiencing problems with speech as well. So for assessment of speech, this instrument was used. Result: The client’s total score was 62 out of 100. He scored 29 on expressive subscale whereas he scored 38 on receptive subscale. Interpretation: The score of 62 is quite low, which indicates the presence of language deficiency. The receptive score is still better but expressive score is very low. This means that though patient’s ability to comprehend language is intact but the ability of expressive language or speech is damaged.  STROOP Neuropsychological Screening Test: As the client’s frontal lobe is damaged and most of his complaints are related to frontal lobe, so it was necessary to apply a test assessing this brain area. Result: The client scored 84 on color task and 75 on color-word task, out of 112. The pr or extent of brain damage is 0.93. Interpretation: The color-word score is used for assessment. The score of 75 is very low according to client’s age; his score should have been above 99. This shows marked deficit in client’s abilities related to frontal lobe like cognitive abilities, attention, concentration etc. 7. Summary: The client is a 49 years old man named X. He is Civil Engineer. He has a wife and three children and lives in Y. The client has been referred for Neuropsychological assessment by a general physician. He had an accident two weeks before assessment and his head was injured. He is also a patient of diabetes, hypertension, and heart disease. The presenting complaints showed that patient was facing many cognitive as well as neuro-physiological problems including headache, confusion, numbness in left side of body etc. He was also experiencing lack of decision making abilities and problem solving which was affecting his daily functioning especially at home and work. He was experiencing problems in speech as well. The control over his body movements
  9. 9. 8Case Study was also being affected. All these symptoms were causing stress as well. The results obtained by CT scan revealed that he has suffered from hemorrhage in the right fronto-parietal lobe. The results from MMSE and STROOP showed that due to his frontal lobe damage the client’s cognitive abilities specially attention, concentration, judgment, and calculation has been affected markedly. The results from MS Aphasia Screening Test showed that client’s expressive language abilities have been damaged as well. On the other hand scores obtained on Bender Visual Gestalt Test revealed the damage to client’s visual motor and perceptual abilities. Numbness in left side of body shows damage to somato-sensory area in parietal lobe. Further assessment to explore motor deficits is recommended by a specialized physician. References:
  10. 10. 9Case Study Retrieved from: http://en.wikipedia.org/wiki/Traumatic_brain_injury. Retrieved on December 15th, 2014 Retrieved from: http://www.mayoclinic.org/diseases-conditions/traumatic-brain- injury/basics/symptoms/con-20029302 Retrieved on December 15th, 2014 Retrieved from: http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=121 Retrieved on January 14th, 2015 Retrieved from: http://tbims.org/combi/mast/ Retrieved on January 14th, 2015 Retrieved from: http://www.msktc.org/tbi/factsheets/Understanding-TBI/Brain-Injury-Impact-On- Individuals-Functioning Retrieved on January 14th, 2015 Retrieved from: http://www.asha.org/public/speech/disorders/RightBrainDamage/ Retrieved on January 14th, 2015 Retrieved from: http://link.springer.com/referenceworkentry/10.1007%2F978-0-387-79948-3_661 Retrieved on January 14th, 2015

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