Case report
Clinical neuropsychology
Identifying information
Patient: Bouvier
Age: 39
Sex: Woman
Marital status: Married without children
Living situation: Independently with partner
Education: Master’s degree in social work (MSW)
Occupation: Social worker at a non-profit organization
Handedness: Left
Research Setting: Clinical
Referrer: Neurologist
Assessor: Neuropsychologist - NAME
Reason for referral
Ms. Bouvier was referred by her neurologist due to the fatigue, cognitive difficulties and motor
coordination issues she is experiencing.
Assessment goals
The goals of this assessment are to (1) assess cognitive deficits, particularly regarding Ms.
Bouvier’s attention, memory and executive functioning; (2) evaluate Ms. Bouvier’s ability to accurately
recognize and report her symptoms; (3) investigate the interaction of potential disorders and their
impact on Ms. Bouvier daily life and work performance; (4) provide recommendations for workplace
accommodations, treatment and rehabilitation. The patient's goals for this evaluation are: she wants to
know if she is still able to work in the future considering the complaints and she would like to get some
recommendations regarding the fatigue complaints.
Anamnesis
Presenting problems: cognitive, physical, psychological
At present, Ms. Bouvier reports being forgetful and having difficulties maintaining focus. In daily
life, she gets easily distracted during conversations and she tends to repeat questions that have already
been answered a short time ago. Furthermore, she frequently forgets to complete tasks at home, even
with multiple reminders from her husband. For instance, she may forget to eat, to prepare meals, or she
may lose important items like her passport. The complaints have also significantly impacted her
professional life: Ms. Bouvier reports missing client appointments and making mistakes in the
documentation. These tasks were not problematic previously, and now they even require extra time. On
top of that, she struggles with paying attention to details and is becoming worse at multitasking. For her,
problem solving causes increased stress. Ms. Bouvier has frequently needed additional breaks during
work or had to leave early, due to the fatigue she is experiencing. Additionally, her supervisor has raised
concerns about her performance. Ms. Bouvier therefore worries about her job security and fears the
possibility of being placed on medical leave. This could lead to financial instability for her and Mr.
Bouvier, and has become a source of persistent stress. In addition to those cognitive challenges, Ms.
Bouvier experiences physical complaints, including a tingling sensation in her hands and numbness in
one or both legs. The pain she experiences is localized predominantly in her shoulders and her back. She
1
, reports having difficulty falling asleep and sometimes staying asleep, which exacerbates her profound
fatigue. In the referral the specialist wrote that Ms. Bouvier has a mild tremor in both hands, most
noticeable on her left side. Furthermore, mild weakness is reported in the lower extremities, especially
in her legs. Ms. Bouvier has difficulty maintaining balance and a slightly unsteady gait. In addition, the
neurologist reports slight impairments in Ms. Bouvier’s fine motor control. While her eating habits
remain unchanged, Ms. Bouvier mentions she is struggling with low mood and anhedonia. She denies
experiencing hallucinations or suicidal thoughts and does not report any traumatic experiences, apart
from the divorce of her parents.
Onset and course of the current problems
When Ms. Bouvier was doing her bachelor's, she already had some fatigue complaints. At the
time she thought she was tired because of the stress being a student entails. If she would study for a
long time, she would have problems focusing. She did not think much of it then. When she proceeded
with her graduate studies, about five years ago, she began experiencing numbness in one or both of her
legs and a tingling feeling in her hands. These symptoms would come and go. Furthermore, she suffered
from blurred vision. There has been no incident that might have triggered these symptoms, it was more
like a gradual change. Ms. Bouvier felt like these were mild symptoms, hence she did not pay much
attention to them. Nevertheless, while she was finishing her studies, she experienced even more fatigue
than before, and classmates started noticing that she increasingly lost her focus. About three years ago
she started having chronic pain, mostly in her shoulders and back. This was something she could
suppress using normal pain medication, but it still has not subsided to this day. Over the last two years,
the complaints have gotten worse, especially the symptoms regarding attention and forgetfulness.
Functional status
Over the past five years, Ms. Bouvier’s daily functioning has notably changed. Certain tasks take
extra time, and since the past two years she needs to rest more frequently. This includes taking regular
naps and sitting more often. She is no longer able to manage household chores, but remains capable of
maintaining her self-care and personal hygiene. Due to her fatigue, Ms. Bouvier usually avoids driving a
car. However, when she does drive, she reports having no difficulties. Additionally, she experiences
feelings of guilt, considering she is not helping the community anymore with her volunteering.
Unfortunately, she feels too tired to.
History and medication
Ms. Bouvier reports no psychiatric or medical problems during her childhood. She has never
been hospitalized and has never had any surgeries. However, she has been struggling with chronic pain
for three years. Ms. Bouvier has been in therapy once, because of a depression. She discontinued
therapy, because she believed it was no longer necessary. The current appointment is her first time
visiting a neuropsychologist.
Ms. Bouvier has been using standard pain medication for the past three years and reports
occasionally taking multiple doses throughout the day. Ms. Bouvier has also been prescribed sertraline
by the general practitioner due to her low mood and anhedonia for the past month. However, she
reports sometimes skipping a dose, believing the medication is not necessary. Ms. Bouvier furthermore
takes modafinil to help manage her fatigue.
When Ms. Bouvier was in her twenties, she used to smoke five cigarettes on a daily basis. In
college, she used to do marijuana as well. However, she instantly stopped smoking when the numbness
and tingling occurred. At this moment, she denies the use of drugs, although she reports drinking alcohol
at social gatherings. In such social situations, she mentions consuming one to two glasses of either wine
2
Clinical neuropsychology
Identifying information
Patient: Bouvier
Age: 39
Sex: Woman
Marital status: Married without children
Living situation: Independently with partner
Education: Master’s degree in social work (MSW)
Occupation: Social worker at a non-profit organization
Handedness: Left
Research Setting: Clinical
Referrer: Neurologist
Assessor: Neuropsychologist - NAME
Reason for referral
Ms. Bouvier was referred by her neurologist due to the fatigue, cognitive difficulties and motor
coordination issues she is experiencing.
Assessment goals
The goals of this assessment are to (1) assess cognitive deficits, particularly regarding Ms.
Bouvier’s attention, memory and executive functioning; (2) evaluate Ms. Bouvier’s ability to accurately
recognize and report her symptoms; (3) investigate the interaction of potential disorders and their
impact on Ms. Bouvier daily life and work performance; (4) provide recommendations for workplace
accommodations, treatment and rehabilitation. The patient's goals for this evaluation are: she wants to
know if she is still able to work in the future considering the complaints and she would like to get some
recommendations regarding the fatigue complaints.
Anamnesis
Presenting problems: cognitive, physical, psychological
At present, Ms. Bouvier reports being forgetful and having difficulties maintaining focus. In daily
life, she gets easily distracted during conversations and she tends to repeat questions that have already
been answered a short time ago. Furthermore, she frequently forgets to complete tasks at home, even
with multiple reminders from her husband. For instance, she may forget to eat, to prepare meals, or she
may lose important items like her passport. The complaints have also significantly impacted her
professional life: Ms. Bouvier reports missing client appointments and making mistakes in the
documentation. These tasks were not problematic previously, and now they even require extra time. On
top of that, she struggles with paying attention to details and is becoming worse at multitasking. For her,
problem solving causes increased stress. Ms. Bouvier has frequently needed additional breaks during
work or had to leave early, due to the fatigue she is experiencing. Additionally, her supervisor has raised
concerns about her performance. Ms. Bouvier therefore worries about her job security and fears the
possibility of being placed on medical leave. This could lead to financial instability for her and Mr.
Bouvier, and has become a source of persistent stress. In addition to those cognitive challenges, Ms.
Bouvier experiences physical complaints, including a tingling sensation in her hands and numbness in
one or both legs. The pain she experiences is localized predominantly in her shoulders and her back. She
1
, reports having difficulty falling asleep and sometimes staying asleep, which exacerbates her profound
fatigue. In the referral the specialist wrote that Ms. Bouvier has a mild tremor in both hands, most
noticeable on her left side. Furthermore, mild weakness is reported in the lower extremities, especially
in her legs. Ms. Bouvier has difficulty maintaining balance and a slightly unsteady gait. In addition, the
neurologist reports slight impairments in Ms. Bouvier’s fine motor control. While her eating habits
remain unchanged, Ms. Bouvier mentions she is struggling with low mood and anhedonia. She denies
experiencing hallucinations or suicidal thoughts and does not report any traumatic experiences, apart
from the divorce of her parents.
Onset and course of the current problems
When Ms. Bouvier was doing her bachelor's, she already had some fatigue complaints. At the
time she thought she was tired because of the stress being a student entails. If she would study for a
long time, she would have problems focusing. She did not think much of it then. When she proceeded
with her graduate studies, about five years ago, she began experiencing numbness in one or both of her
legs and a tingling feeling in her hands. These symptoms would come and go. Furthermore, she suffered
from blurred vision. There has been no incident that might have triggered these symptoms, it was more
like a gradual change. Ms. Bouvier felt like these were mild symptoms, hence she did not pay much
attention to them. Nevertheless, while she was finishing her studies, she experienced even more fatigue
than before, and classmates started noticing that she increasingly lost her focus. About three years ago
she started having chronic pain, mostly in her shoulders and back. This was something she could
suppress using normal pain medication, but it still has not subsided to this day. Over the last two years,
the complaints have gotten worse, especially the symptoms regarding attention and forgetfulness.
Functional status
Over the past five years, Ms. Bouvier’s daily functioning has notably changed. Certain tasks take
extra time, and since the past two years she needs to rest more frequently. This includes taking regular
naps and sitting more often. She is no longer able to manage household chores, but remains capable of
maintaining her self-care and personal hygiene. Due to her fatigue, Ms. Bouvier usually avoids driving a
car. However, when she does drive, she reports having no difficulties. Additionally, she experiences
feelings of guilt, considering she is not helping the community anymore with her volunteering.
Unfortunately, she feels too tired to.
History and medication
Ms. Bouvier reports no psychiatric or medical problems during her childhood. She has never
been hospitalized and has never had any surgeries. However, she has been struggling with chronic pain
for three years. Ms. Bouvier has been in therapy once, because of a depression. She discontinued
therapy, because she believed it was no longer necessary. The current appointment is her first time
visiting a neuropsychologist.
Ms. Bouvier has been using standard pain medication for the past three years and reports
occasionally taking multiple doses throughout the day. Ms. Bouvier has also been prescribed sertraline
by the general practitioner due to her low mood and anhedonia for the past month. However, she
reports sometimes skipping a dose, believing the medication is not necessary. Ms. Bouvier furthermore
takes modafinil to help manage her fatigue.
When Ms. Bouvier was in her twenties, she used to smoke five cigarettes on a daily basis. In
college, she used to do marijuana as well. However, she instantly stopped smoking when the numbness
and tingling occurred. At this moment, she denies the use of drugs, although she reports drinking alcohol
at social gatherings. In such social situations, she mentions consuming one to two glasses of either wine
2
