1214120: Session 23, Name: Glen Rosales Al4ni976 XX 0H-0421 9/19/2012 0110060016990-wc-01 wec#: CM-2012-09860K Employer: Baker Hughes Dates of Service: 12/01/20 Failed/Cancelled: None Diagnoses: — Somatic Symptom Disorder (F45.1); Adjustment Disorder with Mixed Anxiety and Depressed Mood,(F43.12) ‘Subjective: One:counseling session and no failed sessions during the current reporting period. Focused on cogtitive distortions and maladaptive thinking contributing to his depression and the resulting negative impact on his functioning. Beliefs of being "useless," “nothing helps," "unable to do anything,” everything being too much," etc. Helped pt identify words signifying the distortions, such'as nothing, anything, everything, always, never. Objective: Mood, stable although continues with some episodes of anxiety, affect neutral to euthymic, Motor functioning good, gait much improved. Continue with more upright posture, no limping. F Plan: Continue with outpatient psychological counseling focusing on helping him dispel cognitive distortions regarding his pain and functional limitations. Continue with instruction in behaviorally- specific pain-management techniques for the purpose of improving his overall coping abilities as well as increasing his functional capabilities. Will make effort to decrease his self focus and replace with more other focus on his wife and child. Cognitive-behavioral, psychoeducational, and ‘supportive techniques will be employed. David E. Johnsen, Ph.D. Clinical Psychologist CC: Margaret Bomhoff, Judge David B. Custar, Attorney Paul A. Scott, Attorney12/30/20: Sessions 24-26 Name: Gien Rosales Dos: 4/4976 SSH: 30%-10-0421 Dol: 8/19/2012 Claim#: 0110060016990-WC-01 wec#: CM-2012-09860K Employer: Baker Hughes Dates of Service:. 12/8/20, 12/16/20, 12/29/20 Failed/Cancelled: 12/22/20 Diagnoses: Somatic Symptom Disorder (F45.1); Adjustment Disorder with Mixed Anxiety and Depressed Mood.(F43.12) Subjective: Three counseling sessions and one failed session during the current reporting period. Pt continued to report progress with respect to how he is feeling and functioning over the course of the sessions. He has been helping his wife more with her ebay/online sales and engaging more actively with the family. On 12/8 he commented that he was no longer the "second child” and was feeling "more alive." He is walking more and feeling better now that he is using the cane properly. He wants to check into a motorized scooter so that he can go on outings with the family and keep up with them. His wife had a death in her family during this period and he was more actively involved in helping with the funeral. Apparently, it was what was described as a Native American funeral involvingja lot of rituals and he helped out more than he has in a long time. Participated in biofeedback training along with breathing and relaxation exercises. Engaging in the relaxation techniques at home with good success. Objective: Mood, stable, affect much brighter, Motor functioning continues to be improved. Gait much less antalgic. Thought content still somatically focused but less so than in the past. Plan: Continued outpatient psychological counseling addressing cognitive distortions regarding his pain and functional limitations. Continued focus on behaviorally-specific pain-management techniques including relaxation training, diaphragmatic breathing, guided visual imagery, and biofeedback. Continued focus on decreasing his self focus and increasing the focus on his wife and child. Cognitive-behavioral, psychoeducational, and supportive techniques will be employed. David E. Johnsen, Ph.D. Clinical Psycholdgist CC: Margaret Bomhoff, Judge David B. Custer, Attorney Paul A. Scott, Attorney |41291211 ‘Session 27-30 Name: Glen Rosales Dos: 4/4/1976 SS#: 2XKHK-0421 Dor: 8/19/2012 Claim: 0110060016990-WC-01 wec#: CM-2012-09860K Employer. Baker Hughes Dates of Servi 1/5/21, 1/12/21, 1/19/21, 1/26/21 Failed/Cancelled: None Diagnoses: Somatic Symptom Disorder (F45.1); Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.12) Subjective: Four counseling sessions and one failed session during the current reporting period. Complained of an "exhausting week" during the 1/5 session. Wrapped a couple of presents for his wife. Has been wood carving and making frames with a Dremel tool and feeling good about that but reported being unable to stand for more than 10 min at a time as the pain becomes too great. Addressed realistic vs unrealistic beliefs/cognitive distortions regarding what is "too great.” Also focused on pacing as a means of pain management. Discussed pain medications and past problems that he has had with them. He realizes they are simply not for him and he is learning techniques for managing his pain without using them. He reported the family telling him that he gets loud and verbally aggressive although he does not recognize it. Worked on techniques for increased self awareness, ways to communicate without becoming and communicating anger. He was particulafly pleased with how he had functioned during the week prior to the 1/26 session. He had done much more activity wise than he had done in months, much of which was helping his wife. Spray painted some woodwork. He appears to have finally come to terms with not worrying about being judged or judging others as well. His self esteem is improving with his increased activity in addition to improvement in the familial relationships. Continued to work on breathing, relaxation, distraction, biofeedback for pain management. Addressed treatment completion in one month. Objective: Mood. stable, affect euthymic, animated. No tearfuiness, dysphoria. Motor functioning including gait cohtinues to be close to normal with the use of a cane. Plan: Continue with previously described treatments. Glen is showing significant improvement in his mood, overalf emotional state, behavior, and functioning. He continues to make use of pain management techniques at home. Anticipate completion of psychological treatment with MMI from a psychological standpoint by the end of the month. David E. Johnsen, Ph.D. Clinical Psychologist CC: Margaret Bomhoff, Judge David 8. ;Custar, Attorney Paul A. Scott, Attorney ulSessions 31-33 | Name: Gien Rosales 4141976 20014-0421 ar19/2012 : —_0140060016990-WC-01 WCC#: (CM-2012-09860K Employer: Baker Hughes Dates of Service: 2/2/21, 2/16/21, 2/23/21 Failed/Cancelled: 2/9/20 Diagnoses: Somatic Symptom Disorder (F45.1); Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.12)-resolved ‘Subjective: Three counseling sessions and one failed session during the current reporting period. Having good weeks. One incident reported during the 2/2 session involved his trying to move a sofa. Ended up with severe pain and in bed for two days. He knew that it was more than he should attempt but wanied to feel like "a man” again. Understands that this was a function of distorted thinking. Good leaming experience, however. Addressed being active within the limits that he has learned over time as well as maintaining a balanced perspective. Recognizing the gains that he has made and how much more he is doing compared to where he was months ago. Understands that judging himself based on what he used to do is not a fair comparison. Reminded him of one of the therapeutic goals being pain management and not pain elimination. Continued work with pain management techniques with good success. Pt using techniques at home. 2/23 session spent reviewing, past sessions, goals accomplished. Glen acknowledged significant improvements in:all aspects of his life. He feels much better emotionally, is tolerating his pain much better with greatly improved functioning from where he was. He recognizes how fear had contributed to his perception of being incapable to doing anything, He is pleased with his improved mobility. He will continue using his pain management techniques at home. Objective: Mood balanced, stable. Affect animated, euthymic. Outlook much more positive. Gait normal with the use of the cane. Posture upright. Positional tolerance greatly improved. Plan: Glen has completed 33 psychological pain-management treatment sessions during which he was regular in attendance, actively participated, and made good progress. The anxiety and depression present at the time treatment began have no resolved. No symptoms of the PTSD previously diagnosed by Dr. Longson's psychiatric evaluation are evident. Glen has reached MMI from a psychological standpoint and no longer requires psychological treatment. He possesses the skills to perform the behavioral pain management techniques at home. He is released from my care as of February 23, 2021. He is not TTD from a psychological standpoint although physical restrictions are deferred to his physician David E. Johnsen, Ph.D. Clinical Psychologist CC: MargaretBomhoff, Judge David B.:Custar, Attorney Paul A. Scott, Attorney 1 '