Client History Report Assignment

JONES, Kyle Page 1 of 4

CONFIDENTIAL

About Mr. Kyle Jones

Mr. Jones is a 45-year-old, right handed, male who was referred by his neurologist for a neuropsychological evaluation of changes in thinking following a motor vehicle accident (MVA) on 12/3/2009. He self-identified as being: Italian American (2nd generation). He reported “Roman Catholicism” as his religion. He has an earned doctorate in English and teaches at a private, Catholic university. He is reportedly a very popular instructor—well- liked by his students and colleagues. He has won faculty awards several years for teaching and mentoring students. Information provided by Mr. Jones: Mr. Jones reported he was the restrained driver of an automobile that was rear-ended while stopped at a light. He denied any loss of consciousness at the time of the accident, but reported only vague memories for the events immediately following the accident. He stated he was able to drive his car home after the accident and later attended a soccer game, but has no memory of the game. He reported his wife noticed he was much quieter and less socially interactive during the game and that he “was not making logical decisions”. He went to the emergency department (ED) the following day and was evaluated there for possible spinal and/or brain injuries. Medical records from this evaluation were not available, but according to Mr. Jones he was released the same day and imaging evidence did not reveal evidence of a focal brain or spinal cord injury. Mr. Jones mentioned that he was also involved in an automobile accident when he was a teenager. He said he was a passenger in the backseat and was “cruising” with some of high school friends. He said none of them were wearing a seatbelt. The car was rear-ended and the driver was thrown out of the car and killed. Since then, he as always worn a seat belt. He stated that he has no fears of driving or being in a car. Although he reported that his initial cognitive symptoms did improve over the week following the accident, Mr. Jones continues to report ongoing difficulties consisting of “fuzzy thinking”, reduced attention span, disorganization, losing track of tasks and/or thoughts, and reduced ability to plan and generate new ideas (e.g., writing lectures). He also reported occasional episodes of memory loss for previous events (e.g., does not recall talking to a student after class one day). Since the accident, people have told him he is more withdrawn and he was recently given feedback by president that he needs to become more “engaged”. He also reported reduced coordination when walking and when using his hands to pick up items. He stated he has been experiencing headaches several times per day and recently started physical therapy for treatment of head and neck pain. Mr. Jones stated he recently retained an attorney to assist him in dealing with the insurance company settlement for the above-referenced MVA. Medical history is significant for hypercholesterolemia. He reported being dropped on his head on a cement floor as a child with a brief loss of consciousness, but he denied any cognitive or behavioral sequelae. No other neurological history was reported. Mr. Jones stated he has a history of depression that in retrospect may have started in childhood, although he was not formally diagnosed until he was an adult. He denied every being depressed enough to consider suicide. He said his periods of depression tend to last about 3-6 months but that he does not get depressed every year. The last time he was, Client History Report Assignment

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CONFIDENTIAL

depressed occurred when he went to his high school reunion and he saw the surviving friends who had been in the car when the driver was killed. He has participated in individual psychotherapy on and off for many years and is followed by a psychiatrist for medication management as needed. He described his current mood as stable and non- depressed, although neurovegetative symptoms of reduced appetite and sleep disturbance were reported. He denied a history of regular or heavy alcohol use, tobacco use, or recreational drug use. He stated he likes to unwind at the end of the day with a glass of wine. Mr. Jones reported a normal birth and development, and reached all milestones on time. He has never been diagnosed with any type of learning disability and did well academically throughout school. He completed college and his Ph.D. in English and has been college professor for the past 30 years. He continues to work full-time. In addition to his other responsibilities, he is a member of the institutional review board and reviews approximately 20 grant applications per month. Difficulties with occupational duties since the accident include problems creating new lectures, losing track of his train of thought while lecturing, and difficulty remembering applications he has read. There is family history of neurological disorder—a maternal aunt. His mother died at age 41 of cancer, and his father is living, age 67, and in good health. Mr. Jones has 4 siblings (2 full-sisters, 1 full-brother, and 1 half-brother by his father’s 2nd wife). He is the eldest of the children in his family. His full brother died of colon cancer last year and the younger of his two sisters has a diagnosis of thyroid cancer, but the remaining siblings are in good health. He has 2 children, ages 12 (daughter), and 15 (son), no health difficulties reported. His children are reportedly good students and he has no concerns related to their academic, social or emotional functioning. His daughter and son are both A-students. His daughter said she wants to be a pilot and his son told him he wants to be a dentist. Mr. Jones is married and lives in a house with his wife (age 30) and their children. He remains independent in activities of daily living, including managing finances, driving, and taking care of household chores. He enjoys woodworking in his spare time and also works out on a regular basis (3 to 5 times per week). He plays golf with several of his male friends. He attends church with his wife, their children and his father. Several other members of the extended family attend the same church. His hobbies include fishing and “tinkering on old cars.” He said that he likes to rebuild motors. He reported being proud of having many publications, including 3 volumes of poetry, but that he was even more proud of rebuilding the engine of a 1945 Chevy truck. He said his favorite color is blue and that his daughter bought him a purple shirt for Father’s day. When he looked stunned (he normally wears more conservative colors), his daughter said, “Purple is made of red and blue. You love blue. You love me. You will love this shirt.” He laughed aloud as he told the interviewer this story and said he wears the shirt proudly. His colleagues were initially stunned to see him wear a purple shirt to work. After he told them what his daughter said, whenever they see him in the shirt, someone comments, “Love your blue shirt.” Behavioral Observations: Mr. Jones arrived on time for his appointment. He attend the appointment alone. He was neatly groomed and dressed and ambulated/walked, stood, and sat independently without problems. His social skills were appropriate and he was fully cooperative throughout the evaluation. His emotional affect varied logically with the, Client History Report Assignment

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CONFIDENTIAL

topic being discussed. His energy level appeared a bit low. He did become more animated when he spoke of meeting his wife for the first time and when he spoke of teaching at the university. He appeared motivated to do well and to put forth good effort on testing. His scores on measures of effort were as follows: TOMM: Trial 1 = 49/50, Trial 2 = 50/50, Retention Trial = 50/50; CVLT-II forced choice recognition = 16/16; and are within the normal range. No overt behavioral indications of depression or other mood disturbance were observed and a full range of affect was demonstrated. Tests Administered: Review of records; Clinical Interview; Effort: Test of Memory Malingering (TOMM); General Cognitive Assessment: Wechsler Adult Intelligence Scale- IV; Attention Tests: Digit Span, Semantic Fluency, Lexical Fluency, Trail Making Tests, Paced Auditory Serial Addition Test (PASAT); Language Tests: Vocabulary, Boston Naming Test; Visuospatial Tests: Block Design, Target Cancellation; Learning/Memory Tests: California Verbal Learning Test-II (CVLT-II), Wechsler Memory Scale-IV (selected subtests); Reasoning/Abstraction: Wisconsin Card Sorting Test (WCST), Similarities, Matrix Reasoning; Mood/Affect: Beck Depression Inventory-II; Personality: Minnesota Multiphasic Personality Inventory-2 (MMPI-2) TESTING SUMMARY:

Raw Scores

Normative Data

Current Level*

GENERAL FUNCTIONING WAIS-IV

Full Scale IQ — SS = 118 High Average Verbal Comprehension — SS = 118 High Average Perceptual Reasoning — SS = 117 High Average

ATTENTION WAIS-IV Processing Speed — SS = 105 Average WAIS-IV Working Memory — SS = 117 High Average Semantic Fluency (total) 14 T = 31 Mild Impairment FAS Test (total) 42 T = 47 Average Trail Making Test Part A (time) 24” T = 52 Average Trail Making Test Part B (time) 67” T = 43 Average PASAT (3”) (number correct) 51/60 z = 0.1 Average

VISUOSPATIAL WAIS-IV Block Design ss = 13 High Average Target Cancellation time (errors) 91” (0) — WNL Rey Complex Figure copy 31/36 — WNL

LANGUAGE WAIS-IV Vocabulary — ss = 14 Superior Boston Naming Test 58/60 — WNL

MEMORY CVLT-II

Learning Trial 1 3/16 z = -2.5 Moderate Impairment Learning Trial 5 9/16 z = -1.0 Low Average Total Learning Trials 33/80 T = 39 Low Average Interference Trial 4/16 z = -1.0 Low Average Short Delay Recall 7/16 z = -0.5 Average Long Delay Recall 7/16 z = -0.5 Average Recognition (hits) 14/16 z = 0 Average Recognition (false positive errors) 4/16 z = 0.5 Average

Wechsler Memory Scale-IV Logical Memory I 31/50 ss = 12 High Average

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Logical Memory II 27/50 ss = 12 High Average Visual Reproduction I 41/43 ss = 13 High Average Visual Reproduction II 41/43 ss = 16 Superior

EXECUTIVE FUNCTIONS WAIS-IV Similarities — ss = 13 High Average WAIS-IV Matrix Reasoning — ss = 13 High Average WCST 64 cards (categories) 3 z = -0.3 Average

MOOD Beck Depression Inventory-II 25/63 — Moderate depression

*Based on age and/or education-matched normative data (as available) WNL = within normal limits based on clinical impression; SS = standard score; mean = 100, standard deviation = 15; ss = scaled score; mean = 10, standard deviation = 3; T = T-score; mean = 50, standard deviation = 10; z = z-score; mean = 0, standard deviation = 1