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John Doe (Evaluation report 3) - Coggle Diagram
John Doe (Evaluation report 3)
History and Relevant Information
Other
Age: 48 years old male
Dropped out of school
Living with older brother and his family
No therapy, no speech and lang services, no pain management that was reported
Medical History
30 seconds oxygen deprivation at birth
Severe back pain (sciatica)
Problems
Completing paperwork on time
Scheduling doctors appointments
My thoughts
Motivation, memory, task initiation? pain?
Assessment Information
Testing behavior
distraught - teared up a little at not being able to do tasks (frustration? But he wasn't really angry?)
unconfident
Said he was going to fail when I asked him to do this assessment
Said he can't do certain tasks and didn't try
Co-operative, friendly
Standardized Assessments
MoCA (Montreal Cog Assessment)
Why?
Quick and easy to use. Simple to administer
Measures cognitive function in several domains
Total possible score = 30
26 and above = within normal limits
Information Assessment
Observation
Results and Clinical Summary
Results
Totals
20/30 = mild cognitive impairment according to MoCA scoring.
Strengths
naming, abstract thinking, orientation
Weaknesses
Memory, recall, visuospatial/exec.
Visuospatial/Exec
Alternating Trail = got confused or forgot directions (0/1)
Copy Bed = forgot lines, added extra lines (0/1)
Clock Drawing = contour okay, numbers off, hands off (1/3)
Naming
Full score (3/3)
Attention
Digit Span = full scores (2/2)
Vigilance = full scores (1/1)
Serial 7s = did not attempt (0/3). Said he was going to fail this portion and refused to do it. Started tearing up at this portion because he was distraight/frustrated?
Language
Sentence Repetition = Messed up one sentence (1/2)
Lang. Fluency = full score (1/1)
Abstraction
Full score (2/2)
Memory/Delayed Recall
Immediate recall was good during both trials. Able to remember 2/5 during delayed recall (5 min). remembered 3 with category cue. (2/5)
memory score index 12/15. 2 remembered without cues (2 x 3 = 6). 3 remembered with category cue (3 x 2 = 6). total score = 12. This score does not count towards total MoCA.
Orientation
Full scores (6/6)
Summary
Important information to make it easy to know what is going on
Also included what was not attempted
Recommendations and Interpretations
Recommended he receive speech and Lang services
use compensatory strategies
Freq. + intensity
mild cognitive impairment
Goals
Long term 1: Recall paragraph of important info after 5 minutes
ST1: recall important sentence after 5 min
St2: recall 3 sentence after 5 min
Long term 2: complete tasks in timely manner
ST1: teach comp. strat
ST2: task initatian