College of Public Health and Health Professions
Department of Clinical and Health Psychology
Psychology Clinic
1600 SW Archer Rd, Room G-901
PO Box 100165
Gainesville, FL 32610-0165
Phone: (352) 265-0294
Fax: (352) 265-0096
January 29, 2009
NEUROPSYCHOLOGICAL EXAMINATION
Re:
MR#:
HERNANDEZ, Alba
1726386
DOB: 2/28/1955 (age 52-11)
Seen: 1/28/2009
Alba Hernandez is a 52-year-old Hispanic female seen for neuropsychological
examination. The examination is requested by Kurt Alexander, Esq. of the Rigdon,
Alexander, and Rigdon law firm. Ms. Hernandez is the plaintiff in a lawsuit regarding
injuries sustained in a 1/18/2000 motor vehicle accident in which her car was struck in the
front by another vehicle. At the outset of our examination, the nature of our visit was
explained to Ms. Hernandez, including (a) that I was not, and would not become, a
treating doctor, and (b) that usual confidentiality standards did not apply in this case as
both defense and plaintiff attorneys would have access to my report. The examination,
including the pre-examination interview, was videotaped in its entirety and despite my
objection, the videographer remained in the room throughout the day. The examination
began at approximately 9:00 am and ended at approximately 6:30 pm.
Medical Record Review
Prior to the evaluation, all medical records forwarded by attorney Alexander were
reviewed. A list is provided in the Appendix. In this description, I will focus on those
records relevant to psychological/neuropsychological issues.
EMS/Public Safety records indicate that on 1/18/2000, Ms. Hernandez was the restrained
driver in a midsize car traveling at slow speed when impacted in the front by a midsize
car traveling at moderate speed. Patient’s body struck steering wheel. There was no loss
of consciousness per EMS. GCS was 15 at the scene. She complained of pain in the neck,
right foot, and back. There was an abrasion on the left neck. History was obtained from
the patient. She was transported to the Holmes Regional Medical Center ED in nonemergent status.
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Hernandez, Alba [January 27, 2009] – Page 2
In the HRMC emergency department, she complained of chest, neck, back, and right foot
pain. Evaluation in the ED on 1/18/00 included x-rays, which revealed mild anterior
hypertrophic osteophyte formation at C4-5, mild loss of disc space height at C4-5, likely
to be degenerative. Mild osteophyte formation in thoracic spine was also indicated. She
was discharged on Naprosyn, Robaxin, and Lortab and instructed to follow up with her
PCP in 1 week.
Ms. Hernandez was seen on 1/20/00 by Dr. Netter, complaining of tenderness in upper
back, neck, and right foot. Diagnosis was severe sprain of the right foot, cervical and
upper back spasm and strain, as well as multiple contusions and abrasions.
Ms. Hernandez consulted neurologist Gary Weiss, M.D. in April 2000, with continued
pain complaints, and underwent EMG and nerve conduction studies and MRI of cervical
spine on 5/18/2000. MRI scan revealed disk herniation at C5-6 level and apparently also
at C4-5. EMG study of the right upper limb was consistent with C6-C7 radiculopathy,
though testing was incomplete.
In August, 2000, Ms. Hernandez consulted neurosurgeon Jonathan T. Paine, M.D. with
continued neck pain with radiculopathy. Based on results of neurosurgical evaluation,
surgery was recommended. On 10/26/01, she underwent anterior cervical diskectomy,
anterior cervical disc fusion using cadaveric bone graft, structural allograft, fragment
fixation using 23mm Atlantis plate with 13mm screws” The accompanying records of
Wuestoff Hospital (where the surgery was performed) were reviewed, without evidence
of neurologic or anesthesia-related complications. The remainder of Dr. Paine’s records
during this period documents her uncomplicated postoperative course. Dr. Paine
apparently saw Ms. Hernandez again on 8/24/2007 for evaluation. She continued to have
significant pain, and by that point had tried medications, traction, and a TENS unit. MRI
revealed disk disease above and below the level of the prior surgery. Conservative
treatment was recommended.
A packet of records entitled “Osler Medical” were reviewed, which is actually a rather
disorganized set of records from primary care physicians, physical therapy notes,
neurodiagnostic studies, etc. All of these records are post-accident. Essentially these
records document visits for a variety of complaints, including cough, tooth pain, shoulder
pain, anxiety, depression, upper respiratory infection, bronchitis, migraine headaches
(documented 12/06), tinnitus and hearing loss related to ear infection (4/04), hypertension,
allergic rhinitis, gastroesophageal reflux disease (GERD), and dysphagia. During this
period, she was tried on a number of different medications for depression and she was
taking an antihypertensive (Diovan).
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Hernandez, Alba [January 27, 2009] – Page 3
Records of Cora Rehabilitation were reviewed. These records document physical therapy
treatment between 3/06 and 5/06. The patient continued to complain of pain in her neck,
upper back, and right shoulder. She was on Ambien, Cymbalta and OTC medication.
She was discharged at an uncertain date to a home exercise program with a traction unit.
Records of Antonio Rivera, M.D., a physiatrist, were reviewed. These records are from
May-September, 2006. Main complaints were pain in the right hand, left elbow, shoulder,
and neck. She was also complaining of occipital headaches with fasciculations of the left
eyelid. In light of these problems in the context of an accident history, an MRI of the
brain was obtained (5/15/06 from Neuroskeletal Imaging). Results revealed no evidence
of acute trauma and a few punctuate areas of high signal within the white matter of the
left frontal lobe that may represent some minimal ischemic white matter changes.
Because of the eye fasciculations, an EEG was obtained on 5/18/06. Results revealed
localized epileptiform activity; sharp waves; left and right temporal areas, sometimes
lateralized on the left. Intermittent delta and theta waves, left and right frontal area. The
EEG was interpreted as and consistent with a potentially epileptogenic cerebral
dysfunction in the left and right temporal area that is lateralized to the left. Based on this
finding, Dr. Rivera started her on Ativan at night and referred her to Dr. Riasco-Mazo for
treatment of “epilepsy”. She returned on 6/12/06 and Dr. Rivera noted that the eyelid
fasciculations had resolved and her neck symptoms had improved. She was prescribed a
home cervical traction unit and was referred for sleep studies for possible sleep apnea.
By August 2006 she was on Keppra, prescribed by Dr. Riascos-Mazo, with resolution of
her eye twitching. She was also on Imitrex for migraine headaches as well as Celebrex.
By September, the eye twitching had returned although she was still on Keppra.
Records of Dr. Riascos-Mazo indicate that he had diagnosed “partial seizures”.
Neurological examination was normal. By 7/28/06, his diagnoses were “partial seizures,
migraine headaches, tension headaches, hypertension, depression, anxiety disorder”. On
10/06,06, she returned to Dr. Riascos-Mazo for a followup. She had noted feeling like she
might be having a “nervous breakdown”; it was decided to wean her off Keppra, and
begin a trial of Lyrica , Nortriptyline, and Imitrex. By 12/8/08, here depression was
worse, and it was decided to wean her off Nortriptyline and to start Lexapro and Ultram.
On 1/17/07, Dr. Mazo received a phone call indicating that Lexapro “made her crazy” and
that she could not function. Psychiatric evaluation was ordered because of depression
and anxiety. On 3/22/07 she returned to the office, having seen a psychiatrist and starting
Prozac. Her pain complaints were persisting and she indicated she wanted to see a
surgeon. Referral was made to pain management for chronic pain. Medications at that
time included Lyrica, Relpax, Zanaflex, Mobic, Prozac (switched from Lexapro), and
Ultram.
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Hernandez, Alba [January 27, 2009] – Page 4
Records of Mitchell Greenberg DC contain information about acute evaluation and
chiropractic treatment, but contain nothing of relevance to the current examination.
Records of Omni Healthcare reveal pre-accident treatment for complaints of left mid-back
pain, and lack of energy (7/22/99), and right wrist pain/carpal tunnel syndrome (10/4/99).
Office notes of Ruddy E. Ruiz, M.D., Melbourne Internal Medicine Associates (MIMA)
were reviewed. These records contained the following pertinent information, extracted
and paraphrased from the records: Initial office visit was 2/19/02. She complained of
episodes of chest pain, palpitations, sometimes under period of stress. Mother is in the
home and is developing dementia. History of MVA with eventual surgery by Dr. Paine
was described. Also complaining of headaches after the accident. Medical evaluation
was undertaken. Office visit 5/29/03: Elevated blood pressure; stress at home with the
illness of her son. She is also taking Zoloft. Suggested routine exercise program, started
on Diovan 80mg/daily. Office visit 7/10/03: no specific symptoms; blood pressure good.
Recommended preventative medicine (colonoscopy). Office visit 9/22/04: Symptoms of
dysphagia; was referred to ENT evaluation. Office visit 3/27/04: sore throat/cough.
Prescribed Z-Pak. Office visit 10/5/04: Office visit with complaints of esophageal reflux.
She was put on Nexium. Office visit 11/3/04: Office visit in which nonspecific symptoms
of dysphagia were described. She had been seen by ENT and had shown signs of reflux.
She had lost her son and was feeling depressed, and she was started on Lexapro 10mg
daily. Office visit 12/7/04: had stopped Lexapro due to side effect; was actually better
with the depression. Blood pressure was stable. Office visit 5/25/05: Problems: GERD,
chronic joint complaints for which a referral to Rheumatology was arranged;
hypertension was managed.
The next set of records is relevant to pre-accident medical care. Records from Chris Ogin,
M.D., referenced in an IME by Craig Jones, M.D. (3/5/08) indicated that Ms. Hernandez
had been seen for “health maintenance, reactive airway disease, increased stressors,
lightheadedness, and nicotine dependence” in 1/19/98). She was also treated for right
carpal tunnel (6/98), pain in the left mid-back, lack of energy (7/99), upper back spasm
and strain (7/99), pain in upper back and numbness in right hand (9/99). She had also
been involved in a motor vehicle accident in Bronx, NY in the 1990’s with no known
sequelae.
Records of Janet Anciro, M.D. describe internal medicine visits for a variety of complaints
including right shoulder, arm pain, hypertension. Initial diagnosis was rotator cuff
degeneration. Subsequent visits occurred with the attempt to manage the shoulder pain.
Visit on 3/1/06 additionally established hyperlipidemia and a periodontal infection in the
upper gum area. Anxiety and depression was noted, with the prescription of Lexapro 10
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Hernandez, Alba [January 27, 2009] – Page 5
mg once a day. Subsequent visits for upper respiratory infections are noted. On 12/29/06
migraine headaches were diagnosed and the patient was given a trial of Topamax. It was
noted that her blood pressure was increasing and that she had increasing GERD.
Other medical records from Drs. Rivera, Ruiz, Spalding, and Marcin were reviewed but
do not yield information of additional relevance to neuropsychological examination. All
of these records cover the time period after the 1/18/00 accident, and treatment/evaluation
was rendered for bronchitis, depression, nasal congestion, otitis media, shoulder, arm,
knee, and leg pain.
In summary, the medical records indicate pre-existing pain and stress-related problems.
She suffers from long-standing, pre-existing depression. Since the accident, she has had
a variety of illnesses and symptoms and has been tried on multiple medications and
treatment modalities. It is sometimes difficult to ascertain whether there has been proper
coordination with all aspects of her care or whether, for example, she received adequate
trials of medication to achieve optimal management of her many problems. The patient
appears to have had an acute exacerbation of pain symptomatology as a result of the
accident. She appears to have had excellent improvement in symptoms with original
surgery with gradual recurrence of symptoms over time. Symptoms of cognitive
disturbance (problems concentrating, etc.) are occasionally mentioned in the record, but
not early in the post-accident course. Cardiovascular/cerebrovascular risk factors
(hypertension, hyperlipidemia, smoking) are present and there is a history of such risk
factors in first degree relatives (mother). She has had a variety of intervening stressors
that have exacerbated her depression and anxiety as well. These include the death of her
son from cancer (2004), chronic pain, family stressors (daughter’s post-accident
adjustment difficulties, mother with dementia living in home).
Pre-Examination Interview
Ms. Hernandez indicates that her primary current complaints are (1) pain in the neck to
the back of her head, also affecting the upper back down to the shoulder blade on the
right; (2) difficulty “staying on task” and managing multiple tasks, and (3) depression
related to changes in her ability to accomplish everyday tasks.
Regarding her pain symptoms, she indicates that they occur on a daily basis and were
rated as an 8 on a 10-point scale of severity. She states that she uses pain patches, one for
the pain in her neck, and another one for her arm. She has tried a number of treatment
modalities, including TENS, electrical stimulation, ice packs, and heat, and until recently,
PT. Many of these modalities gave her temporary relief but did not help in the long term.
She states that her pain is made worse by repetitive movement of the head or arm, or by
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Hernandez, Alba [January 27, 2009] – Page 6
physical exertion. If she does heavy work around the house, for example, she will have
increased pain as a consequence.
Regarding her difficulty staying on task, she has noted difficulty with shifting back and
forth between tasks at work, and reports occasional difficulties with managing her
checkbook. She works as Senior Customer Service Representative for the City of Coca;
her work involves working to some extent with the public and with fellow co-workers
and involves working with new construction meters. She states that she has worked for
the City of Cocoa since 1997, and currently works full time. She states that she has not
received recent performance evaluations.
Regarding her mood, she describes herself as depressed and frustrated with her physical
status and its effect on her ability to accomplish everyday tasks. She states that she
doesn’t like to ask others to help her. She indicates that she has recently been on
Cymbalta and that has improved her condition. She states that she has had some
significant stressors, including the death of her son in 2004 from cancer. Sleep and
appetite are not significantly disturbed. She reports using an ice pack at times to go to
sleep, and until recently, was chronically very tired. She underwent a sleep study and
was found to have obstructive sleep apnea. She now uses a CPAP machine, with which
she is 100% compliant. She sleeps approximately 7 hours per night. Appetite is generally
good. Although she has had some difficulty with acid reflux, she feels hungry, but
sometimes skips meals. She denies weight loss.
Ms. Hernandez currently lives with her mother and 21-year-old daughter. Her mother
has apparently been diagnosed with Alzheimer’s disease. The mother is still independent
in basic ADL’s but Ms. Hernandez prepares meals and provides companionship and care.
Her mother spends the day at a day program. Ms. Hernandez drives her mother to the
program in the morning and her daughter picks her up in the afternoon. Her daughter,
Katrina, has had a number of illnesses and had some significant stress-related issues after
the accident. She was also injured in the accident and received some teasing from
schoolmates about a scar on her leg. There was significant tension and conflict between
mother and daughter at that time, for which they received some counseling. Katrina has
completed many hours in cosmetology at Brevard Community College but has not
obtained a degree. She is currently employed a few hours a week.
Regarding past history, Ms. Hernandez is somewhat vague and apologetic with respect to
dates. She was born on 2/28/55 in Bronx, NY and moved to Chicago prior to completing
high school. She was married in 1971, at age 16 to a man she met in her neighborhood;
they remained married until about 1985 and had two children. In about 1973-1974, they
returned to the Bronx and Ms. Hernandez was allowed to come back and finish her high
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Hernandez, Alba [January 27, 2009] – Page 7
school diploma. Mrs. Hernandez and her first husband divorced in 1985. Her 21 year old
daughter, Katrina, was fathered by a different man with whom Ms. Hernandez had a
subsequent relationship. Ms. Hernandez described how she later discovered that this
man died of an overdose. In 1994, she moved to the Melbourne, FL area where her son
was living. Her son, born in around 1974, died of cancer in 2004. Her daughter, now
aged 30, lives close to Ms. Hernandez in the Melbourne area.
Ms. Hernandez has worked continuously since her teenage years. She worked in banking
from approximately 1975 to 1994, rising through the ranks from being a part-time teller to
a Branch Manager position at a bank on City Island, NY. After her move to Florida in
1994, she was employed first as a temp then with a contractor at an airport doing
ticketing for Continental Airlines. Since 1997 she has worked for the City of Cocoa.
Behavioral Observations
Ms. Hernandez arrived on time and unaccompanied to her appointment. She was a
pleasant woman and was generally a good historian, though she sometimes had difficulty
providing specific dates of events. She expressed considerable discomfort associated with
chronic back pain that radiated to both arms. Following the interview, Ms. Hernandez
applied a topical patch to her back for pain relief. She reported mild benefit from the
patch, but continued to struggle with chronic pain throughout the evaluation, rating her
pain level as 7 out of 10. She requested breaks from testing every two hours to stretch her
legs, which provided additional pain relief. She easily engaged in conversation with the
examiner. Her conversational speech was within normal limits, and rate and prosody of
speech was intact, as was comprehension. Facial expression was within normal limits
and she maintained a good range of affect and sense of humor throughout the evaluation.
She reported a depression level of 4 (out of 10) throughout the evaluation, but, she
appeared to be more depressed than reported. There was also evidence of anxiety and
she frequently asked about her performance; commenting that she was concerned about
providing the correct responses. She was cooperative, and put forth good effort
throughout the evaluation. Based on these observations, today’s evaluation is likely a
valid assessment of her current cognitive abilities.
Tests Administered
Wechsler Adult Intelligence Scale-III (WAIS-III); Wechsler Memory Scale-III (WMS-III)
including Logical Memory and Visual Reproduction; Boston Naming Test; Controlled
Oral Word Association, Category Fluency (Animals); Judgment of Line Orientation; ReyOsterrieth Complex Figure Test; Benton Facial Recognition; Clock Drawing Test; Trail
Making Test (Parts A and B); California Verbal Learning Test-revised (CVLT-II); Finger
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Hernandez, Alba [January 27, 2009] – Page 8
Tapping Test; Grooved Pegboard Test; Wisconsin Card Sort Test; Minnesota Multiphasic
Personality Inventory-2 (MMPI-2); Test of Memory and Malingering (TOMM).
Test Results
A summary sheet containing raw scores and normative results from all tests administered
is attached to this report.
Symptom Validity/Effort Measures. Several validity indicators were scattered throughout
the evaluation to assess for adequate effort on cognitive testing. Ms. Hernandez’s
performance on all trials of the TOMM was within normal limits and had normal
performance on an embedded measure of effort involving digit span repetition (WAIS-III
Digit Span-RDS). Further, she scored in the normal range when assessing word list
learning in a forced choice format (CVLT-II). Overall, although it cannot be assumed that
Ms. Hernandez provided optimal effort on every measure, there was no indication of
suboptimal effort or of an attempt to exaggerate her problems. Based on these
observations, today’s evaluation is likely a valid assessment of her current cognitive
abilities.
Intellectual Functioning: Based on a Full Scale IQ index from the Wechsler Adult
Intelligence Scale-3rd revision (WAIS-III), Ms. Hernandez’s current intellect is estimated to
be in the average range (FSIQ = 91, 27th percentile) and reflects comparable performance
across Verbal (IQ = 91, 27th percentile) and Performance (IQ = 95, 37th percentile) indices.
Composite indices revealed a Verbal Comprehension Index of 91 (27th percentile), a
Perceptual Organization Index of 103 (58th percentile), a Working Memory Index of 95
(37th percentile) and a Processing Speed Index of 88 (21st percentile). All are in the
average range.
Attention, Executive Monitoring, and Processing Speed: Ms. Hernandez was alert and
oriented, demonstrating an average auditory attention span (WAIS-III Digit Span) of 6
digits forward and 5 digits backwards. She also demonstrated average performance on a
working memory task requiring re-organization of letters and numbers (WAIS-III
Letter/Number Sequencing), and average ability on a task of mental arithmetic (WAIS-III
Arithmetic). As indicated above, her Working Memory Index from the WAIS-III was in
the average range. She scored in the average range on the PASAT, a demanding speeded
task requiring mental computations. Low average performance was achieved on a task
involving the ability to quickly shift mental set (Trail Making Test-Part B, 18th percentile).
Her WAIS-III Processing Speed Index was in the lower portion of the average range,
which is derived from two measures, Digit Symbol (16th percentile) and Symbol Search
(37th percentile). She also performed in the average range on a measure of processing
speed involving visual search and planning (Trail Making Test-Part A, 27th percentile).
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Hernandez, Alba [January 27, 2009] – Page 9
Recent Memory: Ms. Hernandez was given several tasks to assess learning and recall of
new information over 20 to 30 minute delays. On WMS-III Logical Memory, she
performed in the average range during immediate and delayed recall, with similar
performance during recognition testing. On the CVLT-II word list, which additional
requires strategic organization, she started slowly on the first three repetitions, but
attained the 69th percentile (14 words) after five repetitions. Her overall learning score
(42) was at the 21st percentile. Recall following short and long delays was in the average
range. During recognition testing, Ms. Hernandez recognized all words from the target
list, but committed eight false positive errors. On a measure of visual memory (Visual
Reproduction), Ms. Hernandez performed in the average range during immediately (37th
percentile) and had no difficulty recalling the figures following a delay (63rd percentile),
performing in the average range. Her ability to recall a complex figure (RCFT) was in the
average range immediately (69th percentile) and in the superior range (93rd percentile)
after a 20 minute delay, reflecting excellent retention of information obtained during the
copy phase (14th percentile). These scores indicate that Ms. Hernandez was able to retain
practically all initially learned details of this complex figure.
Language and Language Related Functions: Spontaneous speech was fluent and
prosodic, and without linguistic errors. She engaged in conversation easily with the
examiner and maintained conversation that was coherent, and relevant. Verbal
Comprehension from the WAIS-III was in the average range, reflecting intact vocabulary
and verbal abstract reasoning. Performance on a formal test of visual confrontation
naming (Boston Naming Test, 46/60) was impaired in the context of average vocabulary
knowledge (WAIS-III Vocabulary, 25th percentile). She demonstrated low average
performance on a phonemic fluency measure (FAS, 18th percentile) and average ability on
a semantic fluency task (Animal naming, 42nd percentile).
Visuoperceptual and Spatial Tasks: Ms. Hernandez’s performance across visuospatial
tasks was intact. Performance on a spatial task that involved matching line angles
(Judgment of Line Orientation, 56th percentile) was average, as was her ability to match
unfamiliar faces under various lighting and orientation conditions (Benton Face
Recognition, 49th percentile). Visuoconstructional ability was also within normal limits, as
measured by assembly of block designs from the WAIS-III, and she had no difficulty with
detailed visual scanning (WAIS-III Picture Completion, 63rd percentile).
Abstract Reasoning/Problem Solving: Ms. Hernandez demonstrated no difficulty on the
Wisconsin Card Sorting Test, a problem solving task involving generation of mental sets
and use of feedback from the examiner. She completed six of the six categories with a
relatively low number of perseverations and other errors. She demonstrated average
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Hernandez, Alba [January 27, 2009] – Page 10
performance on a spatial reasoning task involving logical inferences about design
progression (Matrix Reasoning, 50th percentile) and had similar performance on a test of
verbal reasoning and logical inferences (WAIS-III Similarities, 25th percentile). She had no
difficulty when copying a large complex figure (RCFT), demonstrating good design
cohesion and organizational strategy.
Frontal Motor Processing: Ms. Hernandez is right-hand dominant. On a measure of fine
motor speed involving finger tapping, she performed in the low average range for her
right hand and in the average range with her left hand. On a task of fine motor dexterity
(Grooved Pegboard) she performed in the impaired (5th percentile) range with her right
hand and in the average range (23rd percentile) with her left hand.
Personality and Emotional Functioning: The MMPI Welsh Code was as follows:
321”’8+7-456/90: L’+-KF/. Validity indicators suggest some reactivity and exaggerated
reponse, probably because of emotional and coping factors. However, the profile is valid
and interpretable. This profile suggests chronic distress regarding physical and somatic
symptoms. Numerous concerns and worries about physical health are noted. Regarding
her health concerns, she may manifest stress physically and may experience exaggerated
reactivity in somatic channels. Significant depressive symptomatology is expressed,
manifested both as negative emotion and anhedonia/malaise. Indications are that her
depression is not just reactive to her physical symptoms, but is of a long-standing nature.
Anger and frustration is evident, and is likely controlled along with other negative
emotions, rather than expressed, further increasing tension and stress. She experiences a
number of chronic family stressors from which she has little respite. Her depression is
likely maintained by a lifestyle that does not provide her with many reinforcing
experiences.
Summary and Opinion
Alba Hernandez is a pleasant 53 year-old woman who underwent neuropsychological
evaluation to examine her cognitive and emotional status in the context of a 1/18/2000
motor vehicle accident. Results of the examination indicate Ms. Hernandez performed
within normal limits on stand-alone and embedded measures of effort and demonstrated
average ability on measures of intellectual function. Attention, working memory,
visuoperceptual ability, verbal fluency, and problem solving abilities were intact. Visual
confrontation naming was impaired. Although her verbal learning was initially slow, she
showed good learning with repetition and intact delayed verbal memory. Immediate and
delayed visual memory was entirely intact. Processing speed was generally in the low
average range and she had no difficulty on tasks requiring efficient organizational and
reasoning skills. On tasks of motor function, Ms. Hernandez exhibited consistently worse
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performance with her dominant hand (right) compared to her non-dominant hand across
measures.
The only statistically abnormal scores in the profile reflect poor performance in visual
confrontation naming, initial learning of a difficult word list, and dominant (right) hand
dexterity. These deficits correlate well with documented findings on MRI, which on
5/18/06, revealed “punctuate areas of high signal within the white matter of the left
frontal lobe that may represent some minimal ischemic white matter changes”. They also
correlate well with her reported difficulty in shifting between tasks at work.
When all data is considered, it is my opinion that, while there may be subtle
abnormalities in neuropsychological function, there is no evidence of trauma-related
neuropsychological impairment. Her abnormal findings are more likely related to the
cerebrovascular changes documented on her 5/18/06 MRI and to the presence of
cardiovascular risk factors, including hypertension, smoking, and hyperlipidemia.
Indeed, it was the radiologist’s opinion that her MRI findings were not traumatic in
nature.
Ms. Hernandez continues to suffer from chronic depression and pain that may affect her
cognitive efficiency and speed. It is not clear that she has been optimally treated for these
conditions through a continuous, systematic program of psychotherapy and pain
management. It would be useful to try a more aggressive behavioral pain management
approach in hopes that it would alleviate some of her distress and would improve the
quality of her life. Given the chronicity of her problems, I would regard prognosis for
significant improvement as guarded. A brief (3-6 month) trial of behaviorally oriented
psychotherapy would also be useful as a way of helping her manage stress more
effectively, to build a healthier lifestyle, and to assist her in developing a broader ranger
of positive and rewarding experiences.
I appreciate the opportunity to evaluate Ms. Hernandez. Please note that I conducted the
full medical record review and clinical interview and am responsible for the
interpretation of results. In accordance with standard practice, Christian Dow, Ph.D.,
Postdoctoral Associate in Neuropsychology, administered and scored the
neuropsychological tests used in this evaluation.
____________________________________
Russell M. Bauer, Ph.D., ABPP/CN
Professor and Chair
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