Joel Wall is a 50-year-old right-handed gentleman who was seen for 65 minutes of interview and records review, in addition to 1.5 hours of testing, scoring, interpretation, and generation of documentation. He is being assessed primarily in regard to the postconcussion syndrome.

HISTORY: The patient was involved in a motor vehicle accident on 04/07 of this year and sustained multiple injuries, including bilateral pulmonary contusions, bilateral pneumothorax, and multiple facial fractures, particularly on the left. He is currently on ventilation. The patient did have an alcohol level of .142 at the time of his admission. He has had some reactive depression. Reportedly, the patient has had several prior concussions and motor vehicle accidents. Previous medical history is also significant for chemical dependency treatment in 2000 and again in 2001. The patient had one prior hospitalization in the psychiatric unit last year with adjustment issues following the suicide of his daughter.

Previous medical history is also significant for rotator cuff repair 3 or 4 years ago. The patient is a chronic smoker at the rate of three packs a day. He has a history of borderline diabetes and hypertension. He has chronic arthritis and a history of peptic ulcers.

CURRENT MEDICATION: Mucomyst, albuterol, ipratropium, bacitracin, bisacodyl, Procrit, heparin, Mycostatin, PCS, morphine, Protonix, and Zosyn.

FAMILY HISTORY: Significant for heart disease in the patient’s father who died at age 52; his mother died at age 65 from cardiovascular accident.

SOCIAL HISTORY: The patient lives in Manytown and is currently a widower. He has no surviving children, is a graduate of a 2-year vocational college in the East, and has completed military service.

INTERVIEW: The patient admits he feels somewhat reactively depressed; however, he states that this is nothing like the depression he had about 2 years ago. The patient states that this depression is primarily attributed to being laid off at his place of employment. He feels he is doing well with it. He does not have suicidal ideation. He states that several years ago he became a devoted Buddhist and that has been supportive for him during difficult times. He states that he could go home and stay with one of his nephews with whom he is close.

BEHAVIOR OBSERVATIONS: In the interview, the patient is lying in his bed. He is on the ventilator and so has to communicate primarily by writing, which he does quite efficiently. I do note, however, that the patient includes some extra letters or sequences his letters at times. When asked about this, the patient attributes it to not having his reading glasses. The patient is able to tell me about his accident, although we asked when it happened and he writes that it occurred “July 4”; and when asked whether he is sure about this, he insists that it is true and that it happened after he had been to the local theater to see an adventure show he had been looking forward to. He insists it was on July 4th. He seems surprised and embarrassed when told that, in fact, it happened in April. The patient states that prior to the accident he was actively employed as a carpenter and, when he had time, worked in the evenings and weekends as a painter.

TESTING: On testing, the patient is found to be alert, motivated, and cooperative. A good rapport was easily established. The patient was confident, relaxed, and focused. Of note is the fact that the patient was wearing wrist restraints, which did interfere slightly with some of the testings. The patient did not appear bothered by this. He displayed no difficulty with the comprehension or retention of test instructions. He was careful and reflective in his approach to testing tasks. Test results are believed to be a valid reflection of his current abilities.

The patient proves to be well-oriented today (8/8). He has an excellent fund of personal and current information (6/6). He has excellent performance on a test of foresight and planning (Porteus Maze Test: 121/121). The immediate verbal span of concentration is average at 6 forward and 5 backward (50th percentile). Verbal block-tapping span is better yet at 6 forward and 6 backward (91st percentile).

Copying of simple figures is performed well (14/14), as is matching simple figures (4/4). Immediate memory for simple designs is average (58th percentile). After a delay, however, he is noted to lose one of the designs and invert another one. His recollection of the other two is as it was initially. With recognition cueing, he does well (3/4).

Learning of a 9-word categorized list (California Verbal Learning Test) reveals an identifiable learning curve (4, 6, 8, 9, 9). The introduction of a distractor list results in mild retroactive inhibitions (7/9), but the patient improves his performance with semantic cueing (8/9). After a delay, he has retained this information. Semantic cueing is not helpful, but with recognition cueing, he is able to identify correctly all 9 of the 9 list items with no intrusive error.

The patient’s response to the Beck Depression Inventory-II results in a score within the normal or non-depressed range (1/3). The patient relates only that he has less energy than he used to have. He denies feeling of dysphoria or sadness and denies any element of suicidal ideation.

IMPRESSION: Joel Wall was involved in a serious motor vehicle accident and received significant facial and upper-torso trauma; he also suffers from the postconcussion syndrome. He has been on a ventilator and has had some reactive depression. Current testing would suggest that the patient is not experiencing significant depression at this time. From a cognitive standpoint, he seems to be doing quite well, and there is really minimal if any evidence of cognitive dysfunction.

I will work with Joel to help him with a better understanding of the specific obstacles to his being discharged and any progress he might be making on these. When I spoke to him, he indicated that he had no idea of what the specific issues were and certainly had no sense of a timeline, which was a source of great frustration for him.

The patient also identifies that he has benefited from pastoral care from the local Buddhist monk, and hopefully they will be able to follow up with him on a regular basis to provide support.

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ICD-10-CM DX CODE(S): __________________________________