109| Adult Fact-Finding Case 1

[Music] Welcome everyone to Navigating Neurocycology, a voyage into the depths of the brain and behavior, brought to you by INS. I'm Ryan Van Penn. And I'm John Bologna, and we are board-certified neuropsychologists, which I can finally say because Dr. Ryan Van Penn, here's officially board certified through the American Board of Professional Psychology, ABAAP. He's all self-assured now that he has as many letters after his name as I do. I'm going to have to get another degree or credential to reestablish my superiority here. But seriously though, a huge congratulations. I know I've joked with you that in the past I was confident you could have passed without ever having studied, which is not to mean that the exam process is easy because it's definitely not, but it's a statement to how knowledgeable and competent of a clinical scientist that I know you to be even before going through the process. Of course you did work very hard and put a lot of time and effort into preparing for the exam, and you absolutely deserve to have joined the ranks. So really this is a big deal. Thanks John. That means a lot. I appreciate it. It is really nice to be finished with the process. And thanks to you, John, for helping me study, along with Megan Collier, Steve Careya, Jeff Tremont, Rob Mapu, and Zach Merz. It takes a village, right? Those are all the people who helped me study for the oral exam, so I really appreciate it. All right, enough praise. We'll get back to Navinero. So we have a new type of episode today. This is a clinical fact find where I play the role of examiner and Ryan plays the role of Examini. In fact, we recorded this episode in a few other fact finds while Ryan was studying for ABAP a few months ago. So the recording was part of his actual practice for the oral exam. We wanted to simulate the real procedure as much as we could. So we set a timer for about 50 minutes and I sketched out an outline and then filled it in along the way just as someone would do for the ABAP oral exam. John shared his screen so that I could view the cognitive data which I talk through as part of the process. For any of you who would like to follow along with the test scores, we include them in our show notes at navinero.com/109. The show notes also include links to resources for practicing fact finds and a document with all the relevant background information from this case. So you could consider doing this fact find with a partner first and then coming back and listening to our episode later. This was my second practice fact find prior to oral listening back to it. There were some things I think I did well in others that could be improved. As you're listening, think about how you approach fact finds and what you might have done differently to me and what you might do similarly. And we edited out the silence which is why the audio you hear is less than 50 minutes. Keep in mind that I have never been an ABAP oral examiner so my approach as a mock examiner for Ryan is just based on my having gone through the process a couple of years ago and all of my reading about the exam process. We don't have any insider information from ABCN and we don't reveal any confidential information about the oral exam process. This fact find is purely an educational exercise. Also similar to the clinical case presentations that we release on Navnero. This was a real case but I changed background details for the sake of anonymity to protect the identity of the patient. We plan to release more of our fact finds that we did in preparation for Ryan's exam as well as a mock ethics pin yet. We're interested to hear your thoughts about this new type of episode so please email us at [email protected]. If this turns out to be a popular format, then we'll consider getting other examiners to do mock cases including pediatric ones. We'll debrief about how it went and provide some tips in the outro so stay tuned after the fact find part. And with that we give you Ryan's fact find case number one. Okay I have a 50 year old white woman who was referred to me by physical medicine and rehabilitation and that's all I'm going to give you. Can I have some more background on her for example handiness, language history, place of birth, culture? Sure she's right-handed, English is her only language and she is born and raised in the west coast of the US. All right is there any other information about the referral what the referring provider from PM and R asked for from me in neuropsychology? Yeah her work situation and returning to work is the primary reason for the referral. And I understand I might never see this information is returned to work following anything in particular an event symptom a diagnosis from the referral. We can get into that later you mean? Yeah sure. All right so what does she say our patient what does our patients say in terms of her presenting problem? Cognitive physical psychological symptoms, course of symptoms, etc. Yeah so she said that she feels great and that she doesn't notice any cognitive issues. Okay does she notice any any physical symptoms at all recently any psychological symptoms? No physical symptoms so she said her mood is pretty good although her mood was affected by the pandemic. It's all I have from her better current mood. I'll circle back to mood. Does she have any difficulties with basic or instrumental activities of daily living? I can give examples of helpful. From her report she's independent for basic ADLs. She manages some of her finances without difficulty. Although she occasionally makes mistakes balancing her checkbook. She manages medications but her sister oversees the weekly pillbox filling process. She has watch alarms to prompt her to take meds but she occasionally forgets still. She's capable of managing household chores. You just technology anything else you want to know about? Driving. She has not not driven for a while. Am I allowed to know how long she has not driven for? 10 months. You mentioned return to work. Do we know how long she has been out of work for? Yeah about 10 months. Just to be thorough if not redundant. Do we know of anything that happened about 10 months ago? Anything medical, psychological, neurological that is available? Yeah something did happen about 10 months ago but I'll hold off on the details for right now. Regarding basic background information just to fill in a few gaps if I may, relationship, marital status? Never marry no children. Any partner romantic relationship? No not at the moment. How about her living situation? Does she live alone or live with anyone? She currently lives with her parents. She was on her own in the past. Did she move in with her parents 10 months ago? Or do we know when she moved back? Okay. All right independent for basic ADLs, maybe some variability in other IADLs. So let's talk more about her psych history and current symptoms. She said her mood is pretty good. The pandemic had an effect. So I'll start with current mood and current psychological symptoms. Anxiety, irritability, personality change. Any of that? For her reports, there are no uncharacteristic behaviors, no drastic personality change. She said she's a little bit less health conscious than she used to be. That was the only symptom that she reported. Any hallucinations, delusions reported or available? No. Any psychological treatment currently or in the past? Medications, therapy, ECT, anything like that? No treatment. Currently no formal psychiatric diagnosis or treatment in the past. She said that she had a pretty stressful job and had normal ups and downs in her mood related to the situation had work. Psych medications? No. How's her sleep? I'm wondering about insomnia, initiation, maintenance difficulties. She said that she sleeps well. She gets over eight hours a night. Generally feels rested. She thinks she snores. She's never had a sleep study. She denied any rembehavior disorder symptoms. Any observed apneas that we know of? No. Not that we know. Any other parasymneas, diagnosed or other sleep disorders? No, nothing else. Sleep related. Okay. Substance use history. So I'm wondering about current problematic use of alcohol or illicit drugs or any history. She doesn't use alcohol now and she denied any history of problematic use. She denied current or past use of illicit substances. Doesn't use tobacco. Okay. And that includes cannabis marijuana, no history. Yep. Right. No regular use. history. Yep. So moving on to her medical history and I'm wondering what information might be available. Medical diagnoses, medication list, medical testing. Sure. I can tell you that she has long-standing history of hypertension and hyperliplidemia, which were uncontrolled. She had a thyroid removal in the past. Let's see. In terms of medications, she is on a statin and she's on an anti-hypertensive. Aside from that, she is taking vitamins and supplements. Do we know if she's ever had hypothyroidism, like based on TSH, T3, T4, based on thyroid removal? We don't. We don't know. We can assume that her hormone levels are normal. Okay. Do we have any medical labs for her? No. Okay. Any neuroimaging available or is the radiologist out to lunch? Yep. Yeah. She might be back a little later. I think I already asked this, but just in case. Just want to be sure, is there any information available at this time about any symptoms 10 months ago? If not, let's find, I just want to double check. Yeah. She reports memory issues in the past. So about 10 months ago, memory and some linguistic and problem solving issues as well, that she was reporting. She said things have improved since then. Like I said, now she's not noticing any symptoms. Okay. So she reported memory issues and speech linguistic issues, wondering about chronic versus acute syndromes. So were these rapid onset or are they gradual in development? Yeah. Good question. It was an abrupt onset. Okay. Did she, was she able to provide any additional information about the nature or characteristics of the memory issues or language issues? Like types of things, she had trouble remembering how long it lasted for types of language that were impacted. I'm wondering receptive, expressive, naming, etc. She said no. No, she wasn't. Okay. What about hospitalization? Did she go to the hospital? Do we know are there records? Yep. She was in the hospital 10 months ago and she went through rehab. And so I can tell you that from the speech therapy evaluation, she required moderate assistance for comprehension expression, social interactions, and substantial assistance for memory and problem solving, which improved over the course of her rehabs day, which was how long? Which was a month. And after one month, she was discharged home. Was she inpatient for one month? Yeah. She was on the rehab unit for one month. I think a little bit before that. She was in the hospital too. So let's say month and a half, two months total. And then discharged to her parents' house, were she currently resides? Any other information available at this time about course of her recovery since then, since she was discharged about two months into it? What do you? Yeah. So let me summarize what I know. About 10 months ago, she had acute onset memory issues and some speech language issues. She was hospitalized for whatever event this was. Had rehab, including speech rehab, moderate assistance for language issues, extensive assistance from memory, went home from rehab after about a month from there. Did the patient or any collateral source talk about her recovery at home, like how she was doing with memory and language and any other symptoms she was having? Yep. So there's some collateral information. So her sister joined her for the interview with me. And her report differed a little from the patients. So the sister said that the patient has shown significant improvements, but that she continues to have mild short-term memory issues. Sometimes her piece herself, for example, some impulse control difficulties, like rushing through tasks and being more distractable. She also sometimes rubs her leg or gently rocks in kind of a preservative manner. Her sister said, okay. Associated with all these memory and language symptoms. Were there any physical symptoms like hemiparesis, hemiplegia, tremor, weakness, falls? Do we know if there are any lateralizing physical symptoms on one side of the body more than the other, wondering about brain lateralization? There were no significant motor issues at present. There was some weakness on the left side of her body. Acutely. Was there any neglect, any symptoms of neglect or an attention on the left side of space that were noted? No, not from my notes. From the sister or anyone else records or other cladderals, is there any information about what was noticed acutely? When this event was happening, I have vague information about memory and speech language problems. Was there a facial droop? Was she with impaired awareness, lost consciousness, anything else acutely? No, not that I have or that I can find readily. I think I'll move on for now. Given that, I'm wondering about an acute event. Stroke comes to mind as a potential etiology, probably near the tops of my list, but there are other acute etiologies, infections, seizure. It doesn't seem to fit quite as well with some of those. I guess I can ask. Do we know if it was a traumatic brain injury? Was there a car accident or did she experience a blow to the head in any way? I don't know if I should give you that or not. I'll say no. There were no head injuries. You asked about seizures. Also, no history of seizures. No history of seizures. No seizures and no head injuries that were aware of. At the top of my list, right now, my differential will be stroke, but there are still acute infectious autoimmune type processes that I won't rule out even something like stress-related, although it seems unlikely. Given what I know, I wanted to circle back around and round out family history, family neurological psychiatric history. Parents are in good health. She has a couple of siblings. No known family history. No known neurocognitive issues in her family. Psychiatric illness in the family, no developmental. Nothing that we know of. Got it. Right now, can you talk about sensory motor symptoms? I'm wondering about vision, hearing, taste, smell, weakness, paralysis on one side of the other. Falls. Yes, she denied falls. Her sister reported some subtle occasional balance issues. She ambulated independently to my evaluation. Hearing and vision were adequate for testing purposes. She had glasses. That was it. Can you tell me again, the sister reported some gate, some balance issues that are mild. Some mild balance issues that were on specified. Otherwise. All right. Going back in time, I'm wondering about her early developmental history, mild stones, pregnancy birth, etc. Yeah, normal developmental history as far as we know. How about academics and education, what's her highest level of education? Yeah, actually completed a bachelor's degree. In biology? In her early academic history, any trouble with reading, trouble learning, ADHD symptoms. She said she was an average student. She denied any attentional problems or learning disorder. Average student through college as well. Yeah. So occupationally, I know that she has not been working for a while, I think, about 10 months, along with this event. What has she done in her career, her work history? Yeah, she's been mainly at a managerial level for the past 20 years. What is she managing? Do we know? I don't know the details of it. Yeah. And throughout her work history, had she been fired, been written up, been promoted, done well. As far as we know, she was a good employee and was working well up until about 10 months ago. Yep. Any military history? No. And I'm wondering about any occupational legal issues right now, like short term disability, is she applying for long term disability? What's the status of that? Yeah, she currently receives disability. She's in the process of applying for SSDI, but she is interested in returning to work as soon as possible. She doesn't like receiving disability. And you ask about legal stuff and there is no lawsuits pending, nothing like that. I could make this assumption, but just to be sure, the disability She's receiving right now. Is it short-term disability for her injury ten months ago? Yes. Okay. And you gave me some information from her sister who presented at the appointment. Is there any other information we have from any other collateral source or anything else from the sister? I could go through all the domains. The only other thing was that the sister corroborated most of the functional status that I gave you earlier. Sister double checks, finances and helps with medications and things. Like I said, that's it. Is the sister worried about the patient? Do we have any of that information? Yes. Sister thinks sister estimated that she's about 90% back to her cognitive baseline, although she still worries somewhat about the remaining symptoms and her, you know, what that means for her ability to return to work. Yep. Any other neurological history, any prior history of stroke, traumatic brain injury, COVID-19, other infections, brain surgery? No prior to about ten months ago, there was nothing other than, yeah, what I'd already given you. Yep. And just to be super thorough, there's no other information about the event ten months ago right now, like medical records available, imaging. No, at present, there's nothing else. Okay. So, I will summarize what I know so far. We have a 50-year-old white woman referred by PMNR after an event that happened ten months ago, so I clear exactly what happened. Key to the referral question is, she is interested in returning to work and has not been working for the past ten months or so. We have some patchy details about the event. It was a cute, reported memory and speech linguistic issues abrupt onset. She was in the hospital for a few months, maybe two months, total, including rehab for about a month and per the SLP, a vow, moderate assistance for language issues and even more assistance than that for memory issues acutely. But after about two months, she went home to live with her parents and seems like she's been recovering well based on her sister's report that she's about 90% back to baseline. Most other areas are relatively unremarkable. It's notable that the sister differed in the sister's report then compared to the patient where the patient mostly denied any problems with memory or thinking right now, but the sister still notices short-term memory issues even though the patient is "90% back to baseline." Sister notices her structability being patient being perseverative, having mild balance issues. I didn't mention this earlier, but she has a much less degree. Yep, let's start moving on. Yep. Behave observations, please. Yeah, so she was accompanied by her sister, sister drove her, she was appropriately dressed, groomed, no acute distress. She was open, honest and friendly, poor was easily established, seemed to be an actor to story and had a good understanding of her medical history. What else do you want to know? So insight, affect, I think I already mentioned gain balance, we're all fine, thought process. Positive affect, she had an appropriate range, no evidence of disorder thinking. Yeah, insight, like I said before, she's not noticing any symptoms, but that attracts somewhat with the improvement that her sisters have noticed. Speech wise, she was kind of soft spoken. Her sister said that that was normal. Otherwise receptive and expressive language seemed to be within normal limits, including naming, sorry, including naming to word finding in the conversation. It seems under markable. Yeah, okay. Frustration tolerance, engagement. Yeah, she approached us straightforward fashion, nothing really remarkable. She had seen some of the measures during her speech therapy sessions, benefited from encouragement, seemed to have good stamina. Yep, something I meant to ask earlier is if she's had any prior neuropsych testing. Oh, yeah, good question. No, she hasn't. All right. So I think I'm ready for some cognitive data. Sure. All right, attention processing speed, please. Okay, so I will talk out loud. Four tests of processing speed here are all, and the average range are better. So let me take that off. I typically would actually start before processing speed performance validity testing. Yeah, we will go into the specifics just for the podcast, but you can assume everything was with the normal limits. How about pre-morbid functioning, like a hold measure, like a test of single word reading? Yep. Okay. So the average range, attention, if there are any tests of attention that we're not shown. Yep. So attention, digit span, attention span and working memory looks to be in the average range or better across the board, including RDS, mental calculations and a screening measure where it was fine. So language testing, receptive, expressive naming. So here we have the Boston naming test, confrontation naming, looks to be generally in the average range, but category fluency, animal fluency in particular, she only generated 11 total animals, which is, that test score is exceptionally low. Visual spatial, visual, instructional skills, please. All right. Self design and the average range, line orientation is intact, high average and then the rate complex figure is exceptionally low. And it looks like we have some behavioral observations. She took a Gestalt approach to copying the figure, but it was cavalier and sloppy, made many minor distortions. Okay. Memory, please. All right. CVLT3. So she has a learning curve. She learned over time. It looks to be average to low average in terms of learning as well as the interference list, but even short delay, free and queued recall, or both below average, long delay was below average or exceptionally low. Recognition was low average. She made intrusion errors, but forced choice was adequate. Memory learning, so narrative memory, exceptionally low for immediate and delayed recognition below average. Visual learning and memory, also well below expectations in terms of learning and delayed recall, although her percent retained was decent, but she didn't learn very much to start with. Discrimination was good. That visual memory test. Any other tests of executive functions, aspects of executive functioning we haven't seen. Yeah. All right. Trails B, high average, phoenix fluency, adequate, strup, inhibition, few errors, inhibition switching. Good. So far, multiple areas of executive functioning look good, including matrix reasoning. With Conson, she made more preservative errors than we would expect for her, and we completed two categories, so she was preservative. So executive functions mostly good, but preservative on this Conson sensory motor testing. Okay. Equally low, right and left with a few drops and both right and left hand, so that's not strongly lateralizing when we are another academic achievement or adaptive functioning. All right. Any of those available? No, we don't have that. Yep. Praxis. Normal. Very quick screen and mood psychological functioning. Minimal reported by her. Not surprising, given what she said in the interview. So I will look to summarize what we have. So a comprehensive neuropsych battery in terms of cognitive testing results. Her pre-morbid cognitive functioning is estimated to be about average, although her educational achievement is higher than the population we don't know in her work history as a manager. So we might expect a little more from her. Cognitive test data or valid as far as we know and intact with respect to attention, processing speed, confrontation naming. From there, verbal fluency, I should say semantic fluency was a notable weakness as was visual construction, although that seems to be more based on low attention and destructibility and a rushed approach as opposed to a true visual spatial impairment. So I think stepping back based on testing, it looks like her visual skills aren't at least mostly intact. Also, I haven't heard any report of neglect throughout. Most aspects of executive functioning were generally intact, although she was very perseverative and the most constant in card sorting task. Memory was a notable weakness for her across three different tests. Both initial learning and later recall and recognition was variable. She reports no mood symptoms and she seems to have poor fine-motored exterior in her hands bilaterally without any lateralizing signs there. Any other behavioral observations on testing specific to to test frustration with memory or self-critical comments, anything like that. No. Okay. So I will attempt to summarize what I know of her this far. Once again, 50-year-old white woman with an event 10 months ago, with memory and language problems, medical history of high blood pressure, high cholesterol with poor control. She recovered, she had rehab, she improved, her sister estimates that I should say, I should slow down and say, she was in the hospital or in rehab for two months total, then was discharged home with her parents. Throughout the course of rehab and being home, she improved to where her sister estimates, she's at 90% of her prior functioning. Our patient is looking back to work. So she was motivated to do well in testing. Our patient denied most symptoms, cognitive and psychiatric sister reported more ongoing cognitive symptoms than the patient. On testing, stepping back and looking at her profile, memory is the biggest domain of impairment and it's both verbal and visual, both context and non-context dependent in terms of visual. Not quite sure what to make about the Ray Complex Figure score. It could be an anomaly, maybe it seemed like she rushed and hurried through it and that might explain some of the low score, semantic fluency, it was a notable weakness and a lot of perseverative errors. Not most constant card-sorting task. Other than that, she mostly did well across the board. Important context is that she's applying for disability. So although she also said she wants to return to work, that context could be relevant, although she did fine and performance validity testing. And as I just said, she says she wants to return to work. So I'm not highly concerned about, I'm certainly malingering or feigning or anything like that. I guess at this point, are there any other medical, like neuroimaging or medical tests data available about her acute hospital stay? - Tell me your initial impressions quickly. - Yeah, I think stroke is the most likely ideology and since she was in the hospital for two months total, it probably wasn't a very mild stroke, maybe a moderate stroke, she'd recover well. She also has cognitive reserve and was generally healthy before the stroke. She has a super vascular risk factors, blood pressure cholesterol, which makes stroke even a little bit more likely. We mostly ruled out other causes, TBI seizure. It still could be some kind of infection. I don't have medical labs. In terms of lateralizing the stroke, there's not good data to lateralize right now because motor testing, for example, was impaired equally. I did hear that early on during her hospital stay, she had more left-sided weakness than right-sided weakness, which might suggest a right hemisphere stroke. Although since then, I'm not hearing lateralizing signs and I don't see a strong lateralizing profile and testing. - In terms of anterior versus posterior? - Yeah. So she has some preservative behavior, like on the Wisconsin, but behavioral observations didn't really show much. We would expect someone who is frontal. I'm thinking frontal here to be, to have more unusual behaviors reported by the sister, she would, there'd be personality change. I didn't hear any personality change from the sister. There's no oral production problems. So I'm not quite sure, anterior versus posterior. So posterior, there are no like occipital lobes or no vision problems that I'm noticing. There's no neglect or really anything else that tells me anterior versus posterior right now. I'm pretty agnostic. - Okay. Yeah, so we did just get some imaging in. And 10 months ago, she experienced a right frontal cerebral hemorrhage. I want you to thoughts about what might be a common cause of a hemorrhage in someone's her age? Be helpful to talk through. - Aneurysm, A.D.M. Those are a few ideas. Certainly a schemic stroke is much more common than hemorrhagic stroke. Roughly something like 80% of strokes and adults are a schemic versus hemorrhagic. So to have a pre-existing risk, like susceptibility to a hemorrhage, like the issues I mentioned, it could have been something like that. - Yeah. There were also, there was associated brain compression and a mass effect and she required a craniotomy for the evacuation. - Yep. - And it was an AVM resection as well. So tell me if the brain compression, if the mass effect, excuse me, if that alters any of your thinking about this? - Yeah, it's hard to say because it's been 10 months and she seems to have recovered quite well overall and swelling isn't localized, right? So this was right frontal. There are certain things we might expect from a right frontal stroke. I'm happy to talk about those. Her pattern doesn't look right frontal per se, then again, imaging and cognitive testing don't always agree. 100% is not a one-to-one relationship. So with brain compression, mass effect, increased, ICP, I'd worry to cutely for somebody that can be life-threatening. Obviously that was 10 months ago and she survived. So she seems to have recovered well overall. And just around out the imaging impressions. So although the right frontal hemorrhage was due to a ruptured AVM, there were also acute infarcts involving the left frontal lobe and the left basal ganglia that were noted on imaging as well. So. - Yep. Okay. I haven't said recommendations. - Yep. - This got recommendations, yep. So for her, in the forefront of my mind would be return to work. And I do have concerns for her returning to work. I don't know the details of her position, but she's a manager. So many managerial positions have high demand. So I'd imagine that there's a lot for her to remember at her job. I'll make that assumption and she's really struggling with memory. So I'd be concerned for her return to work. If we were going to, well, before I say that, she also has scattered deficits in semantic fluency. So verbal production, which is important for manager, perseverative behavior on this constant. That could be problematic lack of attention to detail on the right complex figure taken together. I'm concerned if we're going to consider it. I would want it to be very gradual and start slowly. We don't know about something like fatigue as well. These days, she says she's doing okay in terms of her psychological health, but going back to work can be an adjustment. So if at all right now, then I would like her return to work to be gradual. I wonder if she could benefit from any more rehab. I heard about speech rehab, but I wonder about OT or vocational training for her to get back into her old role. It might be that she really can't do that role anymore given the ongoing cognitive problems, in which case therapy might be helpful if adjustment is quite difficult for her. So in terms of IEDL, she's getting some help with finances, medication management, that's not surprising, given memory problems, untesting. And I think that is probably appropriate. And based on what I know about her, it's probably good that she's living at home over time if she wants to move back in her own, that might be a possibility, but she'll be done with care, given her impairments. Control, supervascular risk factors, for sure, hypertension, hyperlipidemia, she's gonna be at high risk of small vessel disease and/or another stroke, which we wouldn't want. Is this some of the high points? - Okay. - I don't know if I would be, if my report would be used as part of a disability application, for example, I'm thinking more about return to work than her disability application right now. - Yeah, this is just four PM and R, primarily, to help with the decision. - Cog rehab could be helpful for her, we wanna think about, you know, who is doing what? We've had some speech therapy. I recommended, or I mentioned the possibility of occupational therapy. There's also Cog rehab, especially focused on memory. Like she has areas that are intact, a lot of areas that are relatively spared and she's doing quite well. And so she would be a good candidate for Cog rehab, I think individual and/or group. And that might help get her to a place functionally, where she'd be even more prepared to return to work. - How about in terms of the likelihood of improvement, you might have said this, but talk about the trajectory that you're thinking of for her. - Yeah, so this happened in her stroke, AVM rupture happened about 10 months ago. So generally speaking, the literature tells us that there's a negatively accelerated curve in terms of recovery from acute brain injury like stroke, such that biologically, in terms of neural reorganization, the most recovery happens early on and less recovery happens later. And most recovery within the first year, typically. That's sort of the quick and dirty, simple understanding. But truly, people can gain function years after stroke, especially if they're using compensatory strategies. So she's near the end of that one year window, but I still think she could benefit. - Okay, I thought that was good. Do you want to debrief about that one or? - Yeah, that's totally. - How was that process for you? - Yeah, it was great. Felt good. Of course it's always sort of fun and interesting to be so in the dark. In my clinical practice, I'm not used to going in so blind, knowing that there's this giant thing that happened. I don't know what it is, and I can't know yet. I have to get all the other information before knowing what the punchline is. That's unique. It's fun. I really feel like a detective. There's pressure, of course, because I want to be right, but I trust the process. I think that's one of the most difficult parts of this is not being able to know, and people get hung up sometimes on that, and they focus on it, and they ask the question three or four different ways when they should just move on. I thought you did a good job with that. Please, can any and all feedback be as harsh as possible? No, I thought you did well. Timewise maybe the interview could have been accelerated slightly. They ended up working out well, but you might want to have a little more time with the test results. How do you recommend being quicker in the interview? The ways that I'm phrasing questions or following up in certain areas where I could have been more succinct? There were a couple of times I felt like you asked the same thing twice, or in a different way. If you ask about sleep, and they give you their answer, I don't think you need to ask about all the details. If it's going to take two seconds, then that's fine. Then your summaries are good, although if that helps you, then that's fine. I don't think you need to summarize quite as much. I think you should talk out loud about why you're ruling something in or out, and you were doing that just fine. I did that enough. I talked out loud enough. I felt like you did that enough. I think the couple of big ones are acute versus chronic, and you did a good job really on saying, "Okay, there was a point of demarcation when something changed." You talked through that, and then you mentioned a few possibilities. This could be TBI. This could be an infection. This could be a seizure disorder. You said all the right things, and why you didn't think it was some of those once more information came out. I thought that process went well. It took you a little bit longer to ask about collateral information. I wanted to ask you that what I do in my clinical practice is I know right up front, and when I read a report, I integrate collateral reports, everything else. For some reason, I got hung up in this idea. I think there's one of the outlines I looked at, and I think it's the Bush Stucky book, The Outline, they recommend lists collateral last. I thought, "Oh, should I pull that out and make the collateral report its own category, and ask about that last?" So I have that last on my outline that I write out. My preference would be just to get it simultaneously with the patient. Would you ask about collateral up front with the presenting problem? That's my preference too. It would have been easier for me as the examiner just to say, "This is what she reported. This is what her sister reported." As long as you get around to it like you did, that was fine, but whatever is easiest for you. There's nothing that I missed. It takes up bandwidth to wonder, "Oh, I'm missing something, and I'm on a time limit here. The one thing I missed in my first practice around effect fighting was family medical history. Whenever you miss something, it's totally human, but it's always like, "Oh, come on." That's where the template and practice come in. Those are the best ways to avoid missing something. You can be saying the correct diagnosis. I remember for mine, I got it, but they're not going to acknowledge it. They probably wouldn't. They'll just say, "Okay, well, what else could it be or talk through?" You're probably never going to know until close to the end what it is. Just say your thoughts and move on to the next bit of information. You don't pass or fail based on guessing the right diagnosis. It's about more than that, which is good. It should be. In terms of the imaging at the end and how I talk through, this was right front-toil, but she also had left front-toil, left basal ganglia, which makes some sense in terms of the cognitive data. Is there anything else that I could have said that would have been even better in terms of functional neuroanatomy or clinical anatomical correlation? No, I don't think so. I'm not sure how much they will prompt you. I was prompting you to tell me what the ideologies of a hemorrhage might be. You could be thinking about that. You don't have to wait for them to ask you that. If they say I did that this was a hemorrhage, you could just, the next thought could be, "Okay, well, in someone her age, this could be an AVM or an aneurysm, just like you said, but I asked you about it." You're not going to be expected to just divulge all the information without any prompting, but it would be helpful, I think, if you thought about what they might be thinking, just into it, what they would want to know. Giving some background information, I think it's good. You said, "Okay, well, the vast majority of strokes are a schematic, something like 80%, so this is a little bit more of a rare case. If you can remember any of that information, I think it's helpful to put it out there." It's good that I said roughly 80%, like it's good to say that because then they know that I have a ballpark estimate of what's right, and I'm not going to be held accountable if it's actually 70% instead of 80 because I'm in the ballpark and that's what they're looking for. Yep. Any information surrounding that particular bit of information that they give you, I think could be helpful again quickly though. You could even stop and ask, I think, one good approach is to say a couple things and to stop and say, "I could say more about that diagnosis if you'd like me to," and then they'll prompt you to keep going or to move on if they don't need it. That's great. Yeah. I definitely plan to do that, especially when I'm giving them something, like when I am summarizing or giving my conclusions, then I try to do that in interviews to, like, from interviewing for a job or a position and they, I list some of my background instead of giving them 15 minutes of a monologue, I'll give them a short version and say, "I can follow up on any of that. Same idea here." Perfect. Yep. What about the way I'm asking these questions? I notice that it's natural for me, like, when I get into sleep, it's natural for me to not just say, "Tell me about sleep," but to give a whole bunch of examples of what I'm looking for within sleep. Is that a good approach? Should I just say, just give the overarching category and then go from there? I like that approach as long as it's quick, so, and like, how you did it was quick. So you said, "Can you tell me about sleep? I'm wondering about apnea or REM behavior disorder symptoms fatigue?" Boom. Like, it could take three seconds to add a few things and that's good because that tells them that you know the specifics. So as long as it's quick, I would say, that's a good approach. Yep. It's normal for me, sort of natural, in terms of how I think about all of the umbrella categories is to give more color in terms of what I'm looking for. I see that as sort of showing them my thinking too. Like, when I say medical history, I might highlight some of the areas of medical history that I'm thinking more about based on what I already know about this person and that tells them about that. Well, I think that's a particularly good approach because you're using the information you've already got, or do you say, "Okay, well, since I know this is an acute event, you know, I'm worried about potential seizures. Can you tell me about the medical history in that regard?" I don't know. You can say one sentence before you ask your question that shows your thinking process of why you're asking that question. One thing that's coming to mind right now is when you're asking for the data, the test results, when you're asking for a particular domain, you should probably also mention why you're asking for that domain. Yeah, you're right. So, you could say that I know she had linguistic issues when she first presented. So, the rehab unit, can you tell me about how language was on testing? Again, if it's succinct, but just any rationale that why you're asking for that domain, I think would be helpful. Yeah, that makes sense. There's so many potential domains that, like, even if I have a strong sense that it's a left hemisphere stroke, I'd still ask for facial skills, and I could say, you know, just to be comprehensive, we don't want to leave right hemisphere function unmeasured. Can you let me know? That sort of thing. Yeah, the rationale could be, I just wanted this to be comprehensive. But I think it's, if there is a good rationale, it's good to say it quickly. Well, John, you know, this is where most interviews end, but I have a few bonus questions for you. Well, I think one thing that can be improved about the field of psychology is if Ryan, left Navinero, so John can just take the full spotlight. You wish. You're assistant to the podcast. All right. Well, that does it for this fact find. Be on the lookout for more of these in future months. And as always, thanks so much for listening and join us next time as we continue to have the brain and behavior. The Navigating Neurosycology podcast and all the linked content is intended for general educational purposes only and does not constitute the practice of psychology or any other professional healthcare advice and services. No professional relationship is formed between us, John Bologna and Ryan Van Pettin and the listeners of this podcast. The information provided in Navigating Neurosycology and the materials linked to the podcast are used at listeners' own risk. Users should always seek appropriate medical and psychological care from the appropriate licensed healthcare provider.