A. Case Scenario:
According to the medical records, Mr. Alexander Medina sought medical attention
through the Emergency Department at Naval Hospital – Jacksonville on November 27, 2009 for
evaluation and treatment of “the worst headache of his life.” He reportedly described this
headache as having a sudden onset with sharp pain on his right side. In filling out the family
history form, he listed brain aneurysm (two brothers) at this first hospital visit. Records from the
hospital indicate that Mr. Medina underwent a CT scan and lumbar puncture, which revealed
negative findings. Subsequently, he was discharged with the diagnosis of “headache,” and was
instructed to take prochlorperazine (5mg). The records show that Mr. Medina returned to Naval
Hospital – Jacksonville Emergency Department three days later for headache and neck stiffness
complaints following a chiropractor visit. He explained that the chiropractor noted elevated
blood pressure during the session (170/115), and urged him to seek medical attention. Mr.
Medina’s blood pressure was recorded as 143/90 upon arrival to the Emergency Department, and
he completed a neurological evaluation yielding negative findings. He was successfully treated
with an epidural blood patch, and discharged from the hospital with the diagnosis of “postlumbar puncture headache.”
Records show that on December 2, 2009, Mr. Medina’s wife, Mrs. Teresita Medina,
called Jacksonville Fire and Rescue Services, explaining that Mr. Medina had an alteration in
consciousness and headache after she found him collapsed on the floor. Upon arrival to the
Emergency Department at Mayo Clinic, he was reported to be bradycardic with labored
respirations and required resuscitation. Neurological examination was significant for
unresponsiveness to pain, pinpoint pupils, and no corneal reflexes. Both CT scan and angiogram
were administered, and results showed a diffuse subarachnoid hemorrhage with enlarged
ventricles, which contained blood (third ventricle), as well as left vertebral artery dissection
(distal to PICA). A right frontal ventriculostomy was preformed, which reportedly resulted in
vast symptom improvement. Additionally, he had a lumbar drain to further improve his
functioning.
Mr. Medina was stable and transferred to Brooks Rehabilitation on December 18, 2009,
where he received inpatient physical, speech, and occupational therapy until December 31, 2009.
At that time, he was reported to have independence in completing basic ADLs. Subsequently, he
engaged in outpatient physical and speech therapies until 1/26/11 and 7/1/10, respectively.
Regarding cognitive functioning, he was reported to have intact memory, with some slight
difficulties in organizational skills, problem-solving abilities, and reasoning.
Patient’s chief complaints at the time of neuropsychological evaluation: Cognitively,
Mr. Medina described difficulty with short- and long-term memory (e.g., forgetting
conversations, item locations, prayers that he once knew). Additionally, he noted difficulty with
word finding and remembering familiar individuals’ names. Per Mr. Medina’s report, his
difficulties are progressively worsening. He is independent in his ADLs, but noted that his wife
helps with all IADLs, such as finances, medication management and driving. He noted that he
stopped driving and doing finances prior to 2009. Emotionally, Mr. Medina reported depressed
mood and irritability. However, his relationship with his wife has reportedly remained positive.
Aside from socializing with his wife, he explained that his involvement in social activities and
activities that he used to enjoy has declined. The extent of his activity throughout the day
reportedly includes watching TV, reading magazines, and occasionally completing Sudoku
puzzles. Physically, Mr. Medina indicated significant difficulty with walking since his ruptured
aneurysm. He reported using a cane and other supports, such as his wife, when walking.
However, Mr. Medina also noted that he is still unbalanced when walking, and recently fell
(without head injury). Although he engaged in physical therapy in prior years, Mr. Medina
explained that he stopped attending sessions, but occasionally does some of these exercises at
home. Mr. Medina indicated that he sleeps approximately 3-4 hours per night, and does not
usually awaken feeling refreshed. For his sleep apnea, he reportedly uses a CPAP every night.
Additionally, Mr. Medina noted that his appetite has been poor since his aneurysm, with a
reported 20lbs decline in weight after the event.
B. Brief Statement of Legal Questions:
In question was Mr. Medina’s present neurocognitive functioning and emotional status
following a subarachnoid hemorrhage secondary to vertebral artery dissection sustained in
December 2009, as well as prognosis for rehabilitation. It is alleged that Mr. Medina suffered
irreparable damage from medical malpractice and the referral asks the neuropsychologist to
quantify those damages that can be attributed to the medical events described above. Also at
question is whether Mr. Medina’s cognitive functioning could be rehabilitated, thus lessening the
amount in damages.
C. Summary of Findings:
General Intellectual Functioning: Mr. Medina performed in the borderline range for
his general intellectual abilities (WAIS-IV Full Scale IQ = 71, 3rd%ile). Domain indices
were also in the borderline range for Verbal Comprehension (VCI = 70, 2nd%ile), Working
Memory (WMI = 71, 3rd%ile), and Processing Speed (PSI = 76, 5th%ile). Perceptual
Reasoning skills were in the low average range (PRI = 84, 14th%ile). His subtest scores
were predominantly between the borderline to low average ranges; he obtained a score
within the average range only for his constructional abilities (Block Design = 25th%ile).
These scores are a departure from his previous neuropsychological evaluation, which found
low average abilities across domains. Mr. Medina showed generally poor performance
across domains of intelligence, which is not consistent with his general presentation and
verbal abilities. He had relatively stronger performance for construction skills.
Achievement: Mr. Medina completed 12 years of formal education (instruction in
English). On the WRAT-4, Mr. Medina scored in the low average range for overall reading
abilities (Reading Composite SS = 80, 9th%ile), and in the borderline range for math
computation (SS = 78, 7th =%ile). His reading performance is poorer than his average range
achievement testing results in 2011. The present academic achievement results do not
adequately represent his educational and occupational attainment (First Class rating
officer, US Navy).
Attention/Working Memory/Processing Speed: During the interview and testing day,
Mr. Medina was alert and oriented to person, place, time, and situation. He was attentive
and able to understand conversations at a normal speed. His abilities to recall a string of
digits in forward and reverse order were in the low average range (WAIS-IV Digit Span
Forward/Backward = 5/3 digits, 16th%ile); however, he scored in the borderline range for
his ability to numerical sequence a string of numbers using working memory (WAIS-IV
Digit Span Sequencing = 4 digits, 5th%ile). Mr. Medina also scored in the borderline range
for his mental arithmetic ability (WAIS-IV Arithmetic = 5th%ile). Processing speed
measures from the WAIS-IV also tested in the borderline and low average ranges (Symbol
Search = 5th%ile, borderline; Coding = 9th%ile, low average). Alternatively, Mr. Medina
showed better performance on a more taxing task testing selective attention and processing
speed (Ruff 2 & 7). He showed average Total Speed (70th%ile) and Total Accuracy
(27th%ile). Mr. Medina showed inconsistencies in his test performance across measures of
attention, working memory, and processing speed. These results would suggest difficulty
with basic abilities, but intact functioning for more complex demands. This finding is
consistent with his previous evaluation.
Memory Functions: On the WMS-IV, Mr. Medina scores ranged from borderline to
average across memory domains. His visual memory was in the borderline range (SS = 74,
4th%ile), while his auditory memory was in the average range (SS = 93, 32nd%ile). Low
average scores were obtained for visual working memory (SS = 85, 16th%ile), immediate
memory (SS = 83, 13th%ile), and delayed memory (SS = 80, 9th%ile). On the CVLT-II,
Mr. Medina scored in the high average range for his word-list learning ability (T = 60,
84th%ile), with superior short delay free recall (SDFR z = 1.5, 93rd%ile) and average long
delay free recall (LDFR z = 0, 50th%ile). Recognition discriminability was intact (z = 0.5,
68th%ile). To assess visual memory, Mr. Medina completed the Rey-O Complex Figure
Test. He scored in the low average range for both his immediate and delayed recalls of a
complex figure (Immediate = 18th%ile; Delayed = 10th%ile). His recognition was also in
the low average range (Recognition = 10th%ile). Of note, Mr. Medina required the most
encouragement to put forth effort on measures of memory. Once prompted to do so, he was
able to correctly answer more items. Consistent with his previous evaluation, the present
findings suggest that Mr. Medina has generally intact memory functions when providing
adequate effort, with a relative weakness in visual memory.
Language and Related Skills: Mr. Medina’s conversational speech was fluent with no
apparent paraphasic errors or word finding difficulties. Although he spoke with an accent,
his comprehension and production of English was intact. On formal testing, his
confrontation naming was in the borderline range (BNT = 43/60, 2nd%ile). He showed little
benefit from phonemic cues (5/17 correct) or semantic cues (0/2 correct). Similarly, his
knowledge of vocabulary was in the borderline range (WASI-IV Vocabulary = 2nd%ile),
and he tended to provide concrete, one-word responses. His letter and semantic fluencies,
however, were in the average range (DKEFS Letter Fluency ss = 11, 63rd%ile; Semantic
Fluency = 7, 16th%ile). Overall, the present findings suggest that Mr. Medina has intact
verbal fluency, but difficulty with confrontation naming and vocabulary. Given that Mr.
Medina’s native language is not English, the present results might be an underestimation
of his language skills in his native language. Compared to the previous evaluation, his
confrontation naming has remained stable, while he showed poorer knowledge of
vocabulary.
Visuoperceptual/Visuospatial Functioning: When asked to copy a complex geometric
figure, Mr. Medina showed intact ability (Rey-O Copy = >16th%ile, WNL) in an adequate
amount of time (Rey-O Time to Copy = >16th =%ile, WNL). His ability to discriminate
lines of differing orientations was in the average range (JOLO = 56th%ile). Mr. Medina
demonstrated intact visuospatial and visuoperceptual skills.
Executive Skills: Executive functions were assessed using the DKEFS and Wisconsin
Card Sorting Test, with disparate performance on both measures. On the DKEFS Trail
Marking Tests, Mr. Medina performed in the average range across all five subtests (ss:
Visual Scanning = 9, 37th%ile; Letter Sequencing = 10, 50th%ile; Number Sequencing = 8,
25th%ile; Number-Letter Switching = 10, %ile; Motor Speed = 11, 63rd%ile). On the
WCST, however, he completed only 2/6 categories successfully, and had a high number of
total errors (WCST Total Errors raw = 72, 2nd%ile). His responses and errors tended to be
perseverative (Perseverative Responses raw = 51, 2nd%ile; Perseverative Errors raw = 42,
4th%ile). Mr. Medina had variable performance across executive function domains.
Although he showed intact flexibility in thinking on visuomotor tasks, he had difficulty
generating novel strategies and self-monitoring.
Motor Skills: Mr. Medina is right-hand dominant. He showed relative difficulty with
speeded finger oscillation bilaterally (Finger Tapping: Left & Right = 1st%ile, impaired).
Additionally, He had low average fine motor dexterity in his right hand (Grooved Pegboard
Right = 18th%ile), but average dexterity in his left hand (Grooved Pegboard Left =
42nd%ile). Overall, these results suggest poorer frontomotor skills for his dominant
compared to nondominant hand.
Personality and Emotional Functioning: On a measure of personality characteristics,
Mr. Medina’s response style is suggestive of potential over-reporting of physical
symptoms, but under-reporting of minor faults and shortcomings that are acknowledged by
most people. His endorsement of items also suggests that he may seem himself as a very
righteous individual and in a very positive light, which may be culturally influenced.
Clinical scales demonstrate that Mr. Medina endorsed a high number of vague neurological
complaints, and proclivity towards developing physical symptoms in response to stress.
Additionally, he endorsed experiencing a high amount of emotional distress, which places
him at-risk for suicidal ideation. Results also demonstrate that he is likely to be dependent
on others for help, and is typically not self-reliant.
On formal neuropsychological testing, Mr. Medina’s performance was fairly
variable, and he demonstrated variable effort throughout the day that improved with
encouragement from the examiners. General intellectual functioning was within the
borderline impaired range, with average performance only shown for construction
skills. He had variable performance across other domains, often inconsistent with his
previous evaluation as well. Relative strengths were seen in more complex tests of
attention and processing speed, verbal fluency, and visuoperceptual skills. Memory
measures showed intact skills, with a weakness in visual memory. Relative weaknesses
were seen in knowledge of vocabulary, confrontation naming, finger oscillation, novel
strategy generation, self-monitoring, and basic attention.
D. Final Opinion:
Overall, it was my opinion that Mr. Medina’s neurocognitive symptoms were multifactorial
in etiology. I discussed the following points during my testimony.
1. Mr. Medina sustained a ruptured aneurysm from a vertebral artery dissection, with
resultant subarachnoid hemorrhage. Across studies of neurocognitive performance in
individuals who have sustained such events, there is high variability in findings with
no consensus of a definitive neurocognitive profile. Additionally, medical records
indicate that Mr. Medina has reported cognitive complaints since 2003. Therefore,
while it is possible that Mr. Medina did experience cognitive changes as a result of
his ruptured aneurysm, it is difficult to know to what extent this aspect alone
contributed to his current neurocognitive functioning beyond his previous
functioning.
2. Mr. Medina’s current emotional status is concerning, and, coupled with his
personality traits, is very likely contributing to his current functioning. Regarding
mood, Mr. Medina endorsed symptoms of depression and is at-risk for suicidal
ideation (denied intent or plan). Studies have shown that depression alone can
contribute to minor cognitive changes, such as difficulty with attention and
concentration. Additionally, Mr. Medina endorsed a coping style consistent with
somatization of psychological difficulties, specifically neurological symptoms.
Therefore, he may experience physical or neurologic symptoms when feeling
stressed or depressed.
3. Mr. Medina’s wife is highly concerned about her husband’s functioning. Although
social support following brain trauma is typically helpful for patients, excessive
dependence can result in potentially slowed recovery. Just as physical
rehabilitation involves the patient engaging in activities to promote use of certain
muscle groups, neurocognitive rehabilitation involves exercises of affected brain
functions (e.g., memory). During testing, Mr. Medina often did not try to provide a
response for test items that were more difficult; however, he was able to answer at
least some of these correctly when encouraged, suggesting intact neurological
functioning for these abilities.
4. Finally, Mr. Medina has a several vascular risk factors and other medical issues,
such as chronic pain. First, chronic pain has been shown to contribute somewhat
to cognitive symptoms, such as poorer attention and memory. Second, Mr.
Medina’s vascular risk factors, such as hypertension, are concerning for his future
brain health. Proper management of these conditions is imperative, and Mr. Medina
would benefit from eating a healthy diet and engaging in physical activity.
E. Self Evaluation of Testimonial Effectiveness:
In my opinion, the forensic case assignment was very valuable for providing us with
hands-on experience in testimony and report writing. Additionally, it was helpful for applying
concepts learned in lectures. Regarding my own experience with this assignment, I was content
with some aspects of my performance, but definitely saw areas that I can improve upon for
future forensic cases.
The strengths throughout my testimony were probably the fact that I stayed relatively
composed (e.g., my voice was not as shaky as I anticipated!), my response to questions about
norms, and that I did not feel pressured to answer questions that I did not know the response to. I
also felt that I argued my conclusions about the case relatively well and stuck to my position,
even with questions about the validity of the findings.
However, my testimony had several weaknesses that I feel can improve with exposure to
forensic experiences. First, I my responses were REALLY long (I surprised myself as much as I
surprised you with my loquaciousness, Dr. Bauer). In a real testimony, I’m guessing the
opposing attorney likely would not give me as much time to talk as Dr. Bauer, Esquire, which
could potentially leave to an incomplete response. In the future, I will need to determine crucial
aspects of the point that I want to get across with my response.
Another weakness was my responses to the series of questions regarding validity
measures. Although I felt that I initially was on the right track with my responding, I did not
push hard enough with my opinion of why the findings were valid. For example, I did not stress
the fact that he was average on some tests enough, and how that compared to his previous
evaluation, as well as the fact that the evaluation provided valuable information regarding
rehabilitation for the patient. I think the phrasing of my responses was really what hurt me here. I
included some of these general points in my testimony, but the points might have come across as
more convincing or stronger with better phrasing.
Finally, I felt like I had a really hard time remembering all of the information about the
patient’s medical history. For example, when Jacob was testifying and had been asked about the
reason for his patient’s previous episode of depression, I was secretly panicking inside because I
forgot the context surrounding my patient’s previous depression, and would have blanked on the
stand if you would have asked me. It doesn’t help that I neglected to bring the big stack of
medical records with me to do a last minute check. Because it was a case with so many medical
records, it would have been important to bring in all of the case materials and have organized
them similar to Joe’s method of using tabs for each record. Making a general outline of the
case’s key points for myself could have also been helpful.
Overall, I felt pretty confident in my final opinion of the case, especially after having
discussed it with you in our meeting. I think the biggest thing that I would need to work on in the
future is conveying that confidence a bit more during testimony, and not cowering when feeling
very pressured. Additionally, I really need to work on how I phrase certain responses to make my
communication more effective.
92