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 هبة 33 عاما, مطلقة ولديها بنت 7 سنوات, تعمل في شركة لإستخراج الفيزا للسفر, تقيم مه الأهل, تشكو من (مش عارفة ولا عايزة اعمل حاجة, مزاج اكتئابي, شعور بالذنب تجاه ابنتها, عزلة, low self esteem , distuebed self image ).. نشأت في أسرة محافظة, مقيدة لحركتها ومثبطة لنموها النفسي, مختزلة البنت في فكرة الزواج..الأب قريب مهتم, والأم ناقدة.. تزوجت منذ 8 سنوات زواج تقليدي واستمر الزواج عام ونصف (كان شيعي المذهب وأجبرها على اعتناق الشيعة, لكنها رفضت فتم الطلاق) المريضة تعاني من موقف الأم و زملاء العمل تجاهها كونها مطلقة.. استشارت طبيب نفسي منذ 9 أشهر و وصف لها مودابكس 50 مجم منتظمة عليه حتى الآن, لكنها لم تنتظم على الجلسات بسبب تكلفتها العالية. المريضة تتقن الرسم والخياطة.. التشخيص المبدئي: Major depressive episode, moderate الخطة العلاجية المقترحة: - زيادة جرعة المودابكس الى 100 مجم - Cognitive therapy focusing on the negative view about self and about the future (expecting failure in work and to be independent) - Further exploration about the possibility of engaging in relationship Diagnosis/Notes Social Allergy Family History Family History No Yes Follow Up ٢٣/١٠/٢٠١٨ (نبيل) واضح انها اتعرضت لضغوط شديدة ومتواصلة من اول مشاكل الزواج وموقف الام منها والمستمر حتى الان وتعتبر ان شخصيتها اتغيرت ومؤخرا صديقتها القريبة جدا تنصرت مما سبب لها صدمة اخرى وقد بدأت تتعب بعد الطلاق من سبع سنين ومن سنتين اتعرضت لتحرش في الشغل واتعمل تحقيق وحصل فضيحة وتم فصل الموظف ومع ذلك هي شعرت بإهانة شديدة والموظف طاردها وهددها بعد ذلك وذهبت لطبيب من سنة وتشعر بانها بلا كارير وغير مستقلة ،وبالفحص هي مكتئبة فعلا وقلق وبارانويد وتشعر بعدم الأهلية وصلت الى درجة القلق الاجتماعي والتهتهة وتحتاج الى دعم نفسي قوي وحميمي ويستحسن من ست مع بروزاك 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
