Steven Assessment Report

Background and Related Information
Steven, a 60;0 male, was referred to the speech-language pathologist by his case worker. He
suffered a traumatic brain injury many years ago and recently has undergone two surgeries to
remove Glioblastoma brain tumors. Following his TBI, he received services from a speech-
language pathologist, psychologist, and physical therapist. Currently, he receives services from
an occupational therapist. Steven has indicated concerns about the speed of his thinking, extent
of independence, energy level, and motivation level.
Steven works at a local farm two days a week. He lives alone in an apartment in an independent
living facility where he is assisted with medication administration.
Assessments:
Observations
While Steven was cooperative throughout the session, he appeared to get frustrated during
various assessment measures. He tended to talk in circles during the case history interview and
had difficulty directly answering questions. He perseverated on some of his answers and took
long pauses before responding to questions. However, Steven completed all the tests and
answered every case history question the speech language pathologist asked.
Cognition and Executive Functions
Steven’s cognitive functioning was assessed using the Cognitive Linguistic Quick Test +
(CLQT+), Everyday Memory Questionnaire, and Functional Assessment of Verbal Reasoning
and Executive Strategies (FAVRES) Task 1. The results of the CLQT+ reveal he has mild
deficits in attention, executive functions, language, and visuospatial skills as well as a moderate
deficit in memory. Steven’s Everyday Memory Questionnaire score was 116, which indicates
that more than once a day he forgets where he puts items, frequently loses things around the
house, and has difficulty remembering what he is told. He reports no difficulty remembering
details about himself, recognizing friends and relatives, recalling faces of famous people, or
following story plots on television. The results of the FAVRES Task 1 were as follows:
Accuracy Standard Score of 70, Rationale Standard Score of 69, Time Standard Score of 26,
Reasoning Subskills Total Score of 15. Steven’s accuracy and rationale scores are slightly below
average. His time and reasoning scores are more than 3 SD below the mean, indicating severe
deficits in his reasoning and problem-solving skills.
Cognitive Linguistic Quick Test + (CLQT+) Results

Domain Index Score Severity Rating
Attention 158 Mild
Memory 140 Moderate
Executive Functions 23 Mild
Language 28 Mild
Visuospatial Skills 73 Mild
Hearing Screening
Steven did not pass his hearing screening and will be referred to an audiologist. Pure tones were
presented bilaterally at 20 dBHL at the frequencies of 500, 1000, 2000, 4000, and 8000 Hz.
Steven responded to all tones presented at 20 dBHL in his right ear and responded to tones
presented at 35 dBHL in his left ear.
Oral Mechanism Exam
An oral mechanism examination was given to evaluate the structure and function of the oral
cavity. The examination revealed weakness of the left facial muscles, which was found to be
within functional limits, as it does not severely impact his speech or swallowing abilities.
Impressions
Stevens areas of weakness include the following: memory, language, visuospatial, attention, and
executive functions. His areas of strength include his memory of personal facts and individuals
in his life and identification of words. Steven’s deficits in memory, attention, and language have
a negative impact on his social interactions with individuals and his ability to work at the level
prior to his injury. Steven’s prognosis for his cognitive communication abilities is fair as he
appears to be motivated and identified areas in which he would like to see improvement.
Diagnosis
Steven presents with a cognitive-communication disorder characterized by attention deficits,
executive functioning deficits, and memory deficits as a result of his TBI, and two brain tumors.
Recommendations
Client qualifies for home and community-based services. At this time, individual therapy is
recommended. Treatment should focus on improving memory and executive functioning,
narrative skills for conversation and compensatory strategies necessary for increased
independence in everyday activities.
Recommend referral to audiologist as patient reported hearing impairment on left side.
The following goals are recommended:
1. Improve memory and executive functioning skills.
a. Steven will be able to follow two step commands with 80% accuracy across three
sessions.
b. Steven will be able to create and implement his own weekly schedule for 5 weeks in a
row.

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What cognitive deficits does Steven present with?

What are Steven's areas of strength?

Background and Related Information

Cognition and Executive Functions

Cognitive Linguistic Quick Test + (CLQT+) Results

Attention 158 Mild

Memory 140 Moderate

Executive Functions 23 Mild

Visuospatial Skills 73 Mild

Oral Mechanism Exam

Recommend referral to audiologist as patient reported hearing impairment on left side.

The following goals are recommended:

1. Improve memory and executive functioning skills.

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