Edit Patient Info Code Gender Gender Male Female First Interviewer Alaaabdelhady asmaaragab Kareemhafzy Kerolos_Botros Mahmoudsa3d Mervat069 monaelgebaly nabilelkot Olabrakat Rehab.mohammed shaymaamady sohaylasamy Aelsherbiny Doaa Abeer Mahmoud Ibrahim Younis Aya Elsayed Mohammed Elsherbiny Mostafa Mahdi Tommie Van Otterloo Shaimaa Mostafa Omkolthom Hamdy Bassem Zaki Kholod Ali Mariam Shehata Seconed Interviewer Alaaabdelhady asmaaragab Kareemhafzy Kerolos_Botros Mahmoudsa3d Mervat069 monaelgebaly nabilelkot Olabrakat Rehab.mohammed shaymaamady sohaylasamy Aelsherbiny Doaa Abeer Mahmoud Ibrahim Younis Aya Elsayed Mohammed Elsherbiny Mostafa Mahdi Tommie Van Otterloo Shaimaa Mostafa Omkolthom Hamdy Date Of First Interview Attachment Summary شاب ضعف وزنه عمره ٢١ سنة يبدو تائها لاب مهندس وام موظفة والاكبر لاخين كان في كلية اعمل وسقط وحول لعلوم كومبيوتر ومتعثر دراسيا، وجاء مع الام والخالة للشكوى من عناده وعصبيته الشديدة لدرجة التطاول عليها ومتعثرة الدراسي وسمنته، وهو جدع واجتماعي وحبوب وله اخ توحدي واخت اصغر وهو يشتكي من الخنقة وعدم التفاهم مع الام وانها تعامله كمعاق بسبب تخنه (مفيش لَبْس هينفعك ويبدو ان الحالة الاخيرة قد بدات منذ اسبوعين مع التعثر الدراسي وضغط الام بدا يشعر بأعراض اكتيابية ولأسباب غير محددة ؟؟؟؟؟ ربما لوجود اخ توحدي في الاسرة واخت اصغر ) واعتماد الام عليه وعصبيتها عليه تراكمت تلك العوامل حتى وصلت الى الاكتئاب مؤخرا وسوف يأخذ بروزاك لمساعدته في المزاج والأكل والحركة والتدخين وربما تيبوفورتين Diagnosis/Notes Social الام : فيه مشكلة بيني وبينه على طول مش مبسوط مني ومش قابل كلامي وعندنا كمان مشكلة الدراسة انه متعثر دراسيا في الجامعة، هو: انا في الجامعة وبرة البيت شخصية وفِي البيت شخصية تانية خالص انا كويس جدا برة لكن مؤخرا بقيت مش عارف أتفاهم معاهم في البيت، (يبكي) مؤخرا بقت أعصابي تعبانة وبتخنق، وبطلت اهزر ومش مرتاح نفسيا وموضوع تخني مش مضايقني لكن ماما بتحسسني اني معاق بسبب تخني، Allergy Family History Family History No Yes Follow Up ١٩/٢/٢٠١٩ اتحسن كتير وأهدى جدا، ولكن مازالت مشكلة الدراسة من وجهة نظر الام معندوش حافز ينجح، وهو يرى ان البروزاك ساعده في عدم العصبية والمزاج ومازالت مشكلة التركيز والتعثر الدراسي، Depressive symptoms Depressive symptoms Depressed mood Anhedonia Decrease concentration Easy fatigability Death wishes Suicidal ideations/plans/attempts Hopelessness / helplessness Sense of suffocation Significant weight loss Insomnia Psychomotor retardation Psychomotor agitation Excessive guilt Manic symptoms Manic symptoms Irritable/elated mood Volubility Flight of ideas Decrease need for sleep Easy distractibility Inflated self-esteem Increase goal directed activities Hyperactivity Involvement in risk activities Delusions Delusions General delusions Bizzare Delusion Acting out No acting out Others Hallucinations Hallucinations Auditory Non auditory Acting out No acting out Perception illusion Others Sleep Sleep Insomnia Interrupted sleep sleepiness Cataplexy Night mares Obstructive apnea/ hypopnea Sleep walking Appetite Appetite Decrease appetite Increase appetite Eating non-food substance Repeated regurgitation of food Restriction of eating Recurrent binge eating Recurrent compensatory behavior Sexual symptoms Sexual symptoms Decrease desire Increase desire Erectile dysfunction Premature ejaculation Anorgasmia Dyspareunia Paraphilia Gender incongruence Agitation Agitation Yes No Aggression Aggression Verbal Physical sexual Destruction Homicide Obsessions/ compulsions Obsessions/ compulsions Obsessions Compulsions Hoarding Body dysmorphia Skin picking Hair bulling Suicide Suicide Death wishes Ideations Plans Attempts current Prior attempts Anxiety symptoms Anxiety symptoms Mental symptoms Physical symptoms Ill-defined fear Specific phobias Panic attacks PTSD Symptoms PTSD Symptoms Intrusive memories (thoughts- feelings- images- nighmares) Hyperarousal Avoiding dissociation Negative thinking Mood changes Somatic symptoms Somatic symptoms Hypochondriasis Conversion Induction of disease or physical symptoms Falsification of physical/psychological symptoms Dissociative symptoms Dissociative symptoms Depersonalization/ derealization Others Neurocognitive symptoms Neurocognitive symptoms Learning / Memory Attention Language Social cognition Self care House keeping Daily activities Ambutaion????? Speech Speech Delay Stuttering Vocal tics Others Intellectual functions Intellectual functions Daily activity Social functions Cognitive ?????? Others Restricted/repetitive behavior Angry/irritable mood Restricted/repetitive behavior Angry/irritable mood loses temper touchy resentful Others Argumentative/defiant behavior: Vindictiveness (Aggression) Argumentative/defiant behavior: Vindictiveness (Aggression) aggressive impulses verbal bullying threatening physical animal People Propities Sixual Stealing Setting fire Others Enuresis Enuresis Primary Secondary Others Encorporesis Encorporesis Primary Secondary Others Attention Attention Attention deficit Forgetfulness Easily distracted Others Activity Activity Hyperactivity Hypoactivity Others Motor Motor Ticks Delayed motor development Soft motor skills Sleep development Gender identity Others Personality-ClusterA Personality-ClusterA Pervasive distrust Detachment from social relationships Odd beliefs / thinking Personality-ClusterB Personality-ClusterB violations of rights Impulsivity Unstable relationships Unstable sense of self DSH Dramatization Ego inflation Personality-ClusterC Personality-ClusterC Social inhibition Difficulty in everyday decisions without help Details oriented Perfectionism Rigidity Anxiety & Cluster C Substance abuse/dependence Substance abuse/dependence Harmfull use Craving Withdrwal symptoms Unable to control use Others Impairement of functioning Impairement of functioning Understanding and communication Getting around Self care Getting along with people Life activities (House hold) Life activities (school /work) Participation in society Others Severity Severity 1 2 3 4 5 6 7 8 9 10 Save Your Changes Back to List
