Selected Clinical Notes of Dr. Adrian Cole, Ph.D.
Clinical Neuropsychology
March 4
Patient: Whittington, William R.
Age: 44
Reason for referral: Subjective cognitive changes; recent errors in executive functioning, attention, and short-term memory. Preliminary neurological examination and imaging unremarkable.
Behavioral observations:
Patient arrived eleven minutes early and spent the majority of the waiting period conducting business by phone. Appropriately dressed, alert, fully oriented, and mildly irritable.
Examiner asked:
“Do you prefer Will or Billy?”
Patient responded:
“William.”
Examiner apologized.
Patient added:
“Nobody calls me Billy.”
Patient reports approximately ten days of what he describes as “stupid mistakes,” including forgetting the security code to his office building, missing a familiar freeway exit, leaving his laptop at a restaurant, and becoming temporarily unable to calculate a basic return percentage during a business meeting.
Patient appeared particularly distressed by the latter event.
“I don’t make mistakes like that.”
Sleep reportedly normal. Alcohol use minimal; patient denies recreational drug use. No known family history of early-onset dementia. Patient denies depression.
When asked about anxiety:
“Not until people started asking me if I have dementia.”
Initial testing demonstrated superior verbal reasoning, high-average working memory, and above-average processing speed. Several inconsistencies were nevertheless observed. Patient failed two relatively simple sequencing tasks, misrecalled four items from a short verbal list, and required repetition of instructions on one executive-function task.
Patient became visibly frustrated after the third error.
“What is wrong with this test?”
Examiner explained that no irregularity had been identified in test administration.
“Then give me a different one.”
Patient was reminded that neuropsychological assessment is not an examination that can be passed through persistence.
“You’ll find there’s usually a way to pass most things by persistence.”
Clinical impression:
Patient appears highly invested in competence, control, and problem-solving ability. Current findings are subtle but inconsistent with estimated baseline functioning. Recommend repeat testing and continued neurological workup.
March 11
Patient contacted office seven minutes after scheduled appointment time to ask when the appointment was scheduled. He arrived twenty-six minutes late and appeared embarrassed rather than irritated.
Repeat testing demonstrated measurable decline in working memory, verbal learning, and executive functioning. Rate of change over seven days is atypical for a conventional neurodegenerative process, particularly given the absence of corresponding neurological findings.
Patient initially questioned validity of computerized testing. Two additional tasks were administered manually. Impairment persisted.
Patient became visibly distressed.
“You need to fix this. I’m losing everything.”
Examiner advised that the cause of the decline had not yet been identified.
Patient asked:
“Then what am I supposed to do?”
MRI remains unchanged and laboratory findings are unremarkable. Expanded neurological consultation recommended. Follow-up suggested in two weeks; patient insisted on one.
March 18
Patient has begun maintaining a notebook labeled:
WILLIAM R. WHITTINGTON — COGNITIVE LOG
March 13: Put toothpaste on razor.
March 14: Forgot attorney’s surname during phone call. Have known him nine years.
March 15: Could not remember difference between gross and net for several seconds.
March 16: Left vehicle running outside residence for approximately forty minutes.
March 17: Could not understand paragraph in contract drafted by my own company.
Today patient scored below average on a task completed in the superior range fourteen days earlier.
Patient repeatedly asked whether stress could account for findings. Examiner advised that stress can produce substantial cognitive symptoms but does not adequately explain the consistency or magnitude of observed decline.
Patient was silent for approximately twenty seconds.
Then stated:
“There’s something I didn’t tell you.”
Patient described an ongoing redevelopment project involving acquisition of an aging residential block for a mixed-use high-rise.
Most owners accepted purchase offers.
One family refused.
Patient described the family only as “Eastern European.” When asked for country of origin, patient stated:
“I don’t know. Somewhere over there. The grandmother had a strange accent.”
Unable to provide further identifying information.
Patient reports that after multiple rejected offers, Whittington Urban Development pursued additional legal options involving unresolved code violations, tax complications, and property-title issues.
Examiner asked whether the family had been evicted.
Patient corrected:
“Relocated.”
Examiner asked whether relocation was voluntary.
Patient did not answer directly.
Patient visited the property on the day the family vacated, prior to demolition. According to patient, the elderly female family member confronted him outside the residence.
Patient recalls her exact words:
“You don’t understand this pain.”
Patient reports that he attempted to respond.
The woman then said:
“You understand nothing.”
Patient states no further unusual event occurred at the time.
Examiner asked whether patient believed the encounter was related to current symptoms.
“I think she cursed me.”
No evidence of humor or metaphorical intent. Patient denies previous belief in supernatural curses.
When asked whether he believes in them currently:
“If you’d asked me eighteen days ago, I would’ve laughed at you. Now I’m not so sure.”
Clinical impression:
Possible emerging magical ideation or delusional attribution in the context of progressive cognitive dysfunction. Patient has begun associating current impairment with a recent emotionally charged interpersonal event.
Patient strongly encouraged not to pursue or confront displaced family until further evaluation.
Patient became agitated.
“Maybe I’m going crazy, but she’s the only explanation.”
Examiner clarified concern was not related to search behavior alone, but to conviction that another person had caused cognitive decline through supernatural means.
“She said I’d understand nothing.”
Examiner clarified:
“She said you understand nothing.”
Patient replied:
“That’s what I said.”
Chart review indicates he did not.
March 23
Unscheduled visit.
Patient arrived carrying three large binders and requested examiner “sign off on the plan.” No such plan had been previously discussed.
Binders contain passwords, legal contacts, financial contingencies, medical records, medication information, names and photographs of family members, maps, cognitive testing results, emergency instructions, and a section labeled:
IF I BEGIN TO QUESTION WHETHER THIS IS REAL
Inside is a typed statement, signed by patient and witnessed by his attorney.
Excerpt:
You are experiencing progressive cognitive decline. You have objective documentation of this. Do not assume later that you imagined it simply because you can no longer understand the evidence.
Patient has additionally retained a private investigator to locate the displaced family.
Clinical impression:
Compensatory planning remains unusually sophisticated and currently rational. Degree of anticipated future impairment implied by these materials is nevertheless concerning.
Examiner again advised against direct confrontation with former property residents.
Patient stated:
“If she’s not the cause of this, why do you write something down every time I bring her up?”
Examiner advised that no evidence currently supports supernatural causation.
Patient responded:
“You’ll see.”
March 29
Marked decline observed. Patient remains capable of complex conversation but demonstrates increasing difficulty retaining multi-step instructions and following abstract reasoning.
During one task, patient accused examiner of changing rules despite instructions remaining unchanged from prior administration. Patient became frustrated, then apologized. This is the first spontaneous apology documented during treatment.
Patient's notebook now contains increasing handwritten material.
One page reads:
FIND MRS. V. FAMILY FROM MARLOWE STREET.
Another:
SHE SAID YOU UNDERSTAND NOTHING. THIS IS IMPORTANT. DO NOT LET DR. COLE TALK YOU OUT OF IT.
Patient was asked what the “V” represented.
He was unable to retrieve the surname.
Patient became visibly distressed and searched backward through notebook until locating the name.
Patient cried briefly.
“I wrote it down because I knew I’d forget it.”
Examiner observed that the system had worked.
“No, I have to write it down because I can’t remember anything without writing it down.”
April 5
Neurological workup remains unrevealing. Cognitive decline continues.
Mood has unexpectedly improved.
Patient reports sleeping eight to nine hours nightly, which he states has not occurred regularly “since college.” He also reports improved appetite and reduced business-related stress.
Patient's sister, Anna Whittington, attended appointment with permission.
Anna describes patient as:
“Weirdly pleasant.”
She immediately apologized for the phrasing.
Collateral history suggests longstanding tension in sibling relationship. Anna reports patient called her voluntarily several days earlier “just to see how I was doing.” She reports he has not routinely done so in approximately fifteen years.
Patient laughed when informed.
“Really? Why wouldn’t I want to call my sister?”
Anna confirmed that this was unusual for him.
Patient considered this.
“Well. That was shitty of me.”
Anna became tearful. Patient appeared confused by her emotional response and offered her a tissue.
Formal testing showed substantial additional decline. Patient demonstrated little visible distress when informed.
“I figured.”
Patient was asked about private investigator.
“Yeah. The lady.”
Unable to recall woman's name. No retrieval with phonemic cue.
When reminded, patient smiled.
“Right. Her.”
No distress observed.
Clinical impression:
Reduced distress despite worsening objective impairment is increasingly notable.
April 12
Patient arrived accompanied by sister. No longer driving.
Three days prior, patient reportedly stopped at a green traffic signal and remained stationary until horns from trailing traffic caused confusion. He then proceeded through the subsequent red light. No collision occurred.
Anna removed access to vehicle afterward. Patient reportedly became angry. Approximately twenty minutes later, patient asked why they had taken Anna’s car rather than his.
His vehicle was parked directly in front of him at the time.
Today patient demonstrated difficulty identifying conceptual similarities.
Question: How are a bicycle and an automobile alike?
Patient looked puzzled.
“Automobile?”
Examiner clarified:
“A car.”
Patient smiled.
“I like red cars.”
Proverb interpretation:
“People who live in glass houses shouldn’t throw stones.”
Patient considered this.
“I can throw a stone really far. Wanna see?”
Examiner explained figurative meaning.
Patient asked:
“What does figurative mean?”
Following assessment, patient appeared cheerful and complimented examiner's shoes. Patient has seen same shoes on multiple prior occasions and has never commented on them.
April 20
Patient no longer actively managing Whittington Urban Development. Operational control has transferred under legal instruments prepared during earlier stages of decline.
Patient appears minimally distressed by loss of professional role.
When asked whether he misses working:
“I worked a lot.”
Examiner asked whether he was good at his job.
“Was I?”
Examiner confirmed that available occupational history indicates significant professional success.
Patient smiled.
“That’s nice.”
During assessment, examiner inadvertently addressed patient as “Billy.”
Patient did not correct the error.
Post-session clarification:
Asked patient whether others call him Billy.
“Probably.”
Chart review confirms initial consultation statement:
“Nobody calls me Billy.”
April 28
Increasing safety concerns.
Reported incidents include leaving stove burner on overnight, attempting to give a delivery driver approximately $1,800 in cash because the driver “looked tired,” and following an unfamiliar dog for several blocks before becoming unable to locate residence.
When asked why he followed the dog:
“I wanted to see where he was going.”
Anna is arranging supervised residential placement. Patient demonstrates markedly reduced insight into impairment. Mood remains positive.
Patient asked examiner:
“Do you have kids?”
Examiner confirmed one daughter, age twelve.
Patient smiled.
“That’s a good age.”
Asked why:
“I don’t know.”
May 7
Patient admitted to Greenhaven Neurobehavioral Residence.
Private room contains familiar personal items selected by Anna. Recognition inconsistent. Photographs occasionally produce emotional response without autobiographical identification.
When shown photograph of himself receiving a municipal development award approximately three years prior:
“That guy looks mad.”
Asked whether he knew subject:
“No.”
Patient was informed photograph depicted him.
He laughed.
“No, it doesn’t.”
Mirror exposure produced brief distress. Patient asked why “that man” was copying him. Mirror subsequently removed.
Language decline is accelerating. Basic reading ability remains partially preserved, though comprehension is substantially impaired.
Original binders no longer useful.
Anna presented first binder.
Patient read title aloud slowly:
WILLIAM R. WHITTINGTON — COGNITIVE LOG
Patient then asked:
“Who’s William?”
Patient subsequently resumed eating pudding.
May 16
Staff report patient is cooperative, sociable, and generally well liked.
Preferred activities include music, supervised garden time, wooden block construction, simple shape sorting, large-piece puzzles, and color matching.
During today’s visit, patient spent approximately eleven minutes attempting to place a triangular wooden piece into a circular opening. Each unsuccessful attempt produced mild laughter rather than frustration.
Occupational therapist attempted to assist.
Patient gently pulled toy away.
“No. I can do it.”
Patient later attempted alternate opening. Triangle fit correctly.
Patient clapped once and smiled broadly.
Examiner note:
Affect notably bright; patient smiling, engaged, and apparently content throughout session.
May 24
Patient unable to state current date, year, occupation, address, or full legal name. Recognizes Anna as familiar and desirable company but does not independently identify relationship.
Observed interaction:
Anna: “Do you know who I am?”
Patient: “Anna.”
Anna: “That’s right. Who am I?”
Patient: “Anna.”
Anna: “I’m your sister.”
Patient: “Okay.”
Anna: “Do you know what a sister is?”
Long pause.
Patient: “You?”
Anna smiled during interaction. She became tearful after leaving patient area.
Mood remains consistently positive. Staff increasingly refer to patient as Billy. Patient responds reliably to name. No objection observed.
June 2
Private investigator originally retained by patient has located the displaced family.
Investigator reports the elderly former resident had lived in the Marlowe Street house for thirty-seven years.
Anna reports ongoing attempts to contact her.
Collateral contact — Anna Whittington:
Anna asked whether examiner's previous interpretation of patient's supernatural explanation as possible magical or delusional ideation remains unchanged.
Examiner advised that no recognized medical mechanism supports supernatural causation.
Anna asked whether any recognized medical mechanism adequately explains patient's current condition.
No adequate explanation could be provided.
June 5
Patient no longer able to complete standardized cognitive testing at clinically meaningful level. Can sort some objects by color, match simple shapes, and follow most one-step verbal instructions.
Pleasant and cooperative.
At conclusion of session, patient pointed toward window.
“Bird.”
A sparrow was present on exterior sill.
Examiner confirmed.
Patient asked:
“Do you like birds?”
Examiner answered yes.
“Me too.”
Clinical impression:
Profound global cognitive impairment. No significant agitation. No apparent psychological distress.
June 9
Plan:
Family meeting scheduled for June 10.
Expected attendees: patient, Anna Whittington, examiner, elderly former resident of Marlowe Street property, and former resident’s adult daughter.
June 10
I stopped taking notes when she entered the room.
William was sitting at the small table beside the window.
Billy, the nurses called him now.
There were six wooden blocks scattered in front of him and a shape sorter between his elbows. He had arranged three red blocks in a crooked tower and was trying to balance a blue one across the top.
Anna stood beside me.
The old woman entered with her daughter, who remained near the door with a set of car keys looped around one finger.
William looked up.
The woman stopped.
For several seconds, nobody spoke.
Then William smiled.
“Hi.”
The old woman stared at him.
He held up the blue block.
“You wanna play blocks?”
Anna made a sound behind me.
Not quite a sob.
The woman approached the table.
William pushed a red block toward the empty chair opposite him.
“You can have the red ones.”
She sat.
Her hands remained in her lap.
William began rebuilding his tower.
Anna said, “Do you know what you did to him?”
The woman’s eyes remained on William.
“Yes.”
“You knew this would happen?”
A pause.
“No.”
It was the first answer that surprised me.
Anna stepped closer.
“You cursed him.”
“Yes.”
I heard myself speak.
“What did you do?”
She looked at me.
“What I said.”
Nothing in her expression suggested the question was difficult.
Anna said, “He doesn’t even know who he is.”
The old woman looked back at William.
He was attempting to balance two blocks in a way that could not possibly work.
They fell.
He laughed.
Anna’s voice broke.
“You said he understood nothing. Well, congratulations. He doesn’t.”
The old woman’s face changed.
Only slightly.
William picked up one of the fallen blocks and held it toward her.
“This one’s good.”
She took it.
Anna said, “You did this.”
The woman looked at her.
“No. He brought this on himself.”
Anna stepped closer.
“Then change him back.”
The woman looked at Billy.
“I can’t.”
“You did this.”
“I know.”
“Then fix it.”
The woman was quiet.
“I can stop it.”
Anna stared at her.
“And everything he’s already lost?”
The woman looked at Billy again.
“I can’t give that back.”
Anna shook her head.
“No. You don’t get to destroy somebody and then sit there and—”
“He destroyed my home.”
Anna looked at her.
“It was just a house. You ruined his life.”
The woman’s expression hardened.
“My father built this house. My children’s heights were still marked on the kitchen door.”
Anna said nothing.
The woman looked back at Billy.
Anna said:
“He was an asshole.”
Billy laughed.
“Asshole is a funny word.”
The woman’s daughter shifted near the door.
Anna continued.
“He was greedy and arrogant and he thought money fixed everything and half the time I couldn’t stand being in the same room with him. But he was my brother.”
William looked up when her voice rose.
“Anna?”
She covered her mouth.
He smiled when she looked at him.
“You’re sad.”
Anna knelt beside him.
“I know.”
He touched her sleeve.
“You can play too.”
She lowered her head.
The old woman watched them.
For the first time, I wondered what she had actually meant when she spoke those words outside the house.
The woman stood.
William frowned.
“You don’t wanna play?”
She looked down at him.
“I am sorry.”
He smiled.
“That’s okay.”
She placed one hand gently against the side of his face.
There was no light.
No sound.
No sudden movement in the air.
William leaned slightly into her palm.
The woman said:
“Enough.”
Then she removed her hand.
William looked at her.
“Can I have the red one back?”
She gave it to him.
He returned immediately to his tower.
Anna stared at the woman.
“That’s it?”
“Yes.”
“When does he get better?”
The woman looked at her.
“He does not.”
“Not even a little?”
The woman said nothing.
She left.
William balanced the red block successfully.
He clapped.
“Look.”
Anna sat beside him.
“Yeah, Billy.”
He pushed another block toward her.
“You do one.”
And she did.
June 17
No measurable decline since June 10.
No recovery of lost function observed.
Mood remains positive.
July 8
Cognitive status stable. Responds consistently to “Billy.” Recognizes Anna as familiar but does not identify relationship without prompting. Engages willingly in block construction and shape-sorting activities.
Affect bright.
No apparent distress.
September 10
No further decline.
Patient completed a six-block tower independently and requested that Anna build one beside his.
Patient remains profoundly impaired.
Affect bright.
No apparent distress.
0 comments