Cognitive Therapy Case Summary

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DOI: 3/21/2016. Patient is a 62-year-old female clerical assistant who sustained a work-related injury to her head, neck, bilateral shoulders, and low back when she tripped and fell in the parking lot. As per OMNI, the patient was diagnosed with blunt head trauma, bilateral shoulder pain, acute neck pain, low back strain, myofascial pain, and neck strain.
Based on the medical report dated 01/05/17, the patient was apologetic upon arrival stating that she was looking for parking. "I have a weird feeling on my left side (pointing to her head)." Upon query, she described this sensation as "tingling" and endorsed that this sensation can trigger headaches.
Upon standing, from a seated position, she reports that she feels more disoriented. This was evidenced during session, as she ambulated with slow gait and looked confused.
She completed functional assessment measures in session, and required assistance in completing these questions in their …show more content…
Plan is for six additional sessions of Cognitive Behavioral Therapy (CBT) to complete the goals and aid the process of psychotherapy. Patient has demonstrated improvement in CBT, but slower than expedited due to transportation barriers and slower processing of the material that has been presented. She is actively engaged in session and is compliant with her homework. Managing her levels of arousal, modifying her thought patterns, increasing her confidence to return to her usual and customary duties, as well as working towards changing her sleep behaviors to manage her pain levels are in progress. She is motivated to return to her place of employment and additional therapy sessions would help focus on fostering this

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