Dr Pham

Richmond Heritage Medical Centre

58 March St

Richmond

NSW 2753

23.04.2024

Re: Edna Wolfshoerndl (DOB: 08.11.1958) NBM10119 MHCP Review

Dear Dr Pham,

Thank you for referring Edna Wolfshoerndl for psychological support in December, 2023, under a Wentworth Healthcare PTS plan. I am her allocated provider and write to provide you with a review at the close of this referral.

Edna attended her first consultation on the 8th of December, 2023. She attended fortnightly to monthly consultations, with a total of five, and her review being held on the 17th of April, 2024.

Initial presentation

At the time of her initial consultation, Edna reported a deterioration in mental health, stating “I’m not sure of myself; I’m not right; I’m scared of everything, where I used to be a strong woman.” Edna considered that workplace bullying was a significant contributing factor and she had had to leave her job as a cleaner after an unsuccessful mediation attempt by the management.

Despite being of retirement age, Edna was not able to receive the aged care pension, which she said was because her and her husband live on acreage. Without her job, financial stressors further increased anxiety. In addition, Edna reported a series of significant life events, including the death of two close friends, the suicide of a neighbour and her daughter being diagnosed with thyroid cancer.

Edna has a background history of domestic violence from her first marriage – physical, emotional and psychological (age 16 – 18). She had two children in this first relationship (now aged 47 and 49), before remarrying her current husband of 34 years. They had two children (aged 30 and 32). Lorraine provides childcare for her grandchildren, two of whom have autism. During this episode of increased anxiety, she worried about her capacity to cope with them.

Edna reported chronic sleep apnoea (on CPAP at night) and chronic pain from bursitis in right leg, treated with (unsuccessful) cortisone injections.

Edna reported constant worry and functional decline. Normally perfectionistic around the house, she had lost interest and stated “I don’t care about anything.”

08.12.23 K10 score: 36/50

Supports

Edna lives at home with her husband, who is supportive.

She is close with some of her children.

She enjoys ukulele lessons and singing in a choir.

She has good friends and enjoys meeting up and chatting on the phone with them.

Update

Over the course of the plan, Edna engaged well in a range of psychotherapeutic interventions to support her recovery. She was able to explore her current situation in context of adverse life events and previous traumas. Through this, she gained insight about the impact of trauma and processed some of these experiences, with good effect.

By March, 2024, Edna reported feeling “really good at the moment; confident. Before I was crying all the time and felt so scared of everything. Now I can listen to the news without any issues.”

At the time of her review on the 17th of April, 2024, Edna reported that she was “doing really well.” She’d Just returned from a month away - cruise with friends then Thailand for a few weeks with family. Stated that the trip went really well. Stated that she was “feeling much better; relaxed; happy; nothing to stress me.”

Is currently studying with her daughters, how to care for her autistic grandchild. Would like to return to work at some point, but just one day per week. For now, happy to study and help her children with childcare. Continues to have bursitis. May need back surgery, however Edna is keen to try physio and exercise first. Sleeping well.

Discussed care plan and agreed that no longer needed support --> close referral. She is aware that she can see you or self-refer if she needs support at another time. Stated that having a professional to talk to has been helpful.

17.04.24 K10: 13/50

MSE

Bright, reactive Speech: normal rate, tone and volume Mood: happy; relaxed Thought form: logical, sequential No alteration in perception No apparent cognitive issues, but not formally assessed. Oriented Good judgement and insight about how stress impacted her emotional wellbeing.

Assessment

Significant recovery and stated that she is now back to her "normal self"

Plan

Close the referral Report back to GP. Should Edna need support at another time, I would be happy to see her.

Regards, Michelle Hookham