Dr Marie Tan-Paredes

My Health North Richmond

Level 1, North Richmond Village

6-16 Riverview St

North Richmond

NSW 2754

08.09.2024

Re: Kim Rogers (DOB: 06/04/1958) NBM10693 Mental health assessment and review

Dear Dr Tan-Paredes,

Thank you for referring Kim Rogers for a GP MHCP in February, 2024 and subsequent Wentworth Healthcare PTS plan for “opinion and management of chronic anxiety, depression, PTSD and ADHD”.

Kim attended her first appointment on the16th of February, 2024. She had fortnightly consultations over the following six months, and you provided her with an additional plan in June, 2024. I write to provide you with a mental health assessment and review of her care, which is ongoing.

Initial Presentation

At the time of her initial consultation, Kim reported a history of anxiety, stemming from multiple psychosocial stressors. She reported feeling stressed, with easy rise to anger, frustration, and stated “I have no patience; everything gets to me.” She stated that she doesn’t hesitate to “tell people off; I just say what I think without caring.” She then regrets it later and experiences low mood. Anger is triggered by other people’s driving; and people not doing things correctly. When anger is particularly heightened, Kim reported thoughts of wanting to “rip my hair out and bang my head against something.”

Background: Kim reported difficulties stemming from her previous marriage, in which she was victim of D/V over years, including verbal, physical abuse and coercive control. At that time, Kim reported feeling too scared to leave and lived in fear for a long time. She continues to feel angry about the abuse and guilt for the impacts experienced by the children’s witnessing of the D/V.

Current: Kim reported an over active mind, with frequent changing of thoughts, from subject to subject. She stated “I can’t switch off worrying about unimportant things. She felt overwhelmed with her workload, and weighed down trying to fit everything in. This was affecting her mood, which she described as “depressed; on the point of crying.”

Kim reported that the symptoms of ADHD include: can’t switch off; doing multiple things at the same time; can’t concentrate; don’t remember things when under pressure; chop and change in conversatioons; can’t sit still; fidget.

Kim likes to go to the gym and keep fit, however with age-related changes to her physique and decreased motivation, she has recently been feeling too tired to work out, which was affecting her mental health and mood.

16.02.2024 K10: 30/50

Mental health history

Diagnosed with ADHD by Dr Mallick on 28.10.2021

Had suicidal ideation during D/V marriage, however children were her protective factor.

Medical history

Hypertension

Osteoporosis

Vaginal prolapse

Bladder repair December 2023

Fractured foot 2022 some reduction in mobility

Breast tumour (fibro adenoma) age 17 (benign)

History of varicose veins

Menopausal hot flushes

Recurrent sinus infections and ear infections.

Developmental history

Born in Erskineville; Grew up in Miranda. The eldest of 5 children.

Father died when Kim was 18 months old (kidney failure). Her mother was in hospital giving birth to Kim’s sister at the time.

3 months later, her mother remarried and she grew up with her step-father, who she had a close bond with.

At 16 years of age, Kim found out that her step-father was not her biological father.

Kim has a full sister, half-sister and half-brother.

Her mother worked in hospitality and step-father was on workers compensation from a back injury throughout her childhood.

Kim reported that her parents fought a lot; and that her father was an alcoholic.

Kim and her sister would stay with their aunties when their mother was unwell and in hospital (schizophrenia). She has unhappy memories of her childhood, including strict parents, who used restrictive and physical forms of punishment, which impacted Kim.

Kim reported a history of being fidgety and difficulty concentrating since childhood.

Attended school till mid-Year 11, then sat exam to join banking workforce.

Left home at age 17 due to difficulties with her mother. Then lived with a girlfriend’s family in Sylvania.

Step-father died in 2005.

From 2006, Kim worked in office administration until the business closed in 2017.

Married 1979; D/V relationship – verbal and physical violence; husband incarcerated from 2013 for criminal activity. They divorced in 2017, whilst husband was still incarcerated.

Age 22: had first child

1987 – 1991: lived in Bilpin, then moved to Blacktown in 1991.

2016 – sold family home and moved to North Richmond.

2018: studied to become a disability worker.

2020: became self-employed

Mother died in September 2023 in QLD.

Currently enrolled in Certificate 3 Business and Medical Administration, for career progression.

Family history

Biological father died of kidney failure in his 20s.

Mother had diagnosis of schizophrenia and depression; had inpatient admissions and ECT; diverticulitis.

Sister has diverticulitis; Barrets; fibromyalgia.

Maternal aunty had breast cancer

AOD

3 glasses of wine per night.

Medication

Vyvanse 40mg – 50mg daily, but stopped taking in March 2024 due to side effects (from GP referral) of increased anxiety and abdominal cramping.

Antidepressant medication – weaned off as reported side effects of ‘unable to think clearly’

Coversyl 5mg tablet daily

Prolia 60mg/l IM every 6 months

Recently commenced on Sertraline, which Kim reports is helping her feel better, but is affecting her weight.

Supports

Sees psychiatrist, Dr Mallick at SJOG.

Works as a disability carer; also on Centrelink benefits as needed.

Has 4 children: Aleisha (44) (has PTSD – police force); Renwick (39); Leander (36) (has OCD and bipolar disorder); Brianna (35) (has anxiety and ADHD)

Has a male friend who she sees once a week.

Lives by herself in own home.

Update

Over the course of the plan, a range of psychotherapeutic interventions were utilised to support Kim’s recovery. Gradually, Kim was able to notice that her mood was improving. She reported feeling “mood is not as low; I’m not feeling as weighed down; I’m less tearful and things are not bothering me as much.” She has been reflecting on and processing past traumatic experiences and current challenges.

At the time of her review in June, 2024, Kim stated "you have helped me heaps; I still suffer anxiety, but I’m feeling more comfortable about some things." An ongoing challenge has been decreased motivation to attend the gym and procrastination in attending to tasks, which was causing stress.

In June, Kim had a set back following employment agency’s late payment of invoices causing financial strain. This took two months to resolve,

MSE

Behaviour: settled in sessions; good eye contact and easy rapport. I have not seen overt signs of restlessness or hyperactivity.

Mood: “I feel better; I'm not irritable; I don't feel anxious”

Affect: congruent with mood; reactive; laughing and smiling; definitely brighter

Thought form: Logical/sequential, with some pauses in sentences to reflect on the word.

Speech: normal rate, tone and volume

Cognition: not formally assessed, however Kim appears to be having memory lapses, with frequent need to pause mid-sentence to think of the word. On explorations, she stated that she has short and long-term memory recall difficulties. She has developed a habit of "waiting for my mind's eye to see it, picture a place to remind me."

Perception: Kim reported occasions of “seeing someone out of the corner of my eye or hear someone call my name” when there is no one there.

Insight: developing insight about mood irritability and reactivity to triggers

Judgement: Kim acknowledges that she can say things to complete strangers without thinking, such as expressing annoyance at people who don't cover their mouth when coughing in public.

Formulation:

66 year old Caucasian woman, living in own home and working as a disability support worker, presenting with anxiety, depression, ADHD and PTSD in background of complex psychosocial stressors, including previous domestic violent relationship

Impression:

PTSD.

Plan

Dr Tan-Paredes, I have some concerns about Kim’s cognitive function. During sessions, she frequently forgets words and has to pause for long periods to think of the word. She may benefit from a cognitive assessment, which I will leave with you to consider.

Kim is currently attending fortnightly sessions under the recent referral. There is no need for further action from you at this time.

Yours sincerely,

Michelle Hookham