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 أحمد رجل عمره 27 سنة، الاول لأخ (اخت من الاب)، الاب يعمل محامي، الام موظفة وهو خريج تجارة ويعمل في التوريدات وغير مرتبط ويعيش مع الام والاخ في العاشر بينما الاب يعيش في الزقازيق (الاب والام منفصلان وعمره 12 سنة)، وقد بدأت الحالة في 2016 وكان في الثانوية العامة وعاني من صعوبة التركيز والخنقة والتفكير المفرط وتكرار غلق الابواب والشبابيك واستمر ذلك حتي 2019 عاني وتكرار التفكير في الكلام مع شعور بالاضطهاد والمراقبة وذهب الي طبيب نفسي وكتب له ادوية ولم يتحسن وفي 2021 خطب وفسخ الخطوبة وعاني بشدة من الشعور بالذنب ولوم النفس واخد اربيرزول وبروزاك وفافرين وانافرانيل وتحسن عدة شهور ثم انتكس ثم خطب ثم فسخ ثم عاد الي الدواء وهكذا وكذلك يعاني من شلل النوم ومنذ شهر وقف الدواء تماما، وبالفحص هو اضطراب شخصية بارانوية مع اعراض الشك، سوء التأويل، حساسية، سرعة الضيق، خمول، فقدان شهية، تقلب مزاجي، لوم النفس، وحدة، انقباض، قلق مفرط، خوف، البطء، تسارع القلب، الدونية، اليأس، التوتر، المراقبة، الغضب، التململ، العصبية، واحيانا ً تبدد الواقع، وهو شاب قريب وعاطفي لأب بارانوية لوام وشديد العنف ولأم لوامة ورغم المرض وبدايته المبكرة من الطفولة والحمل الوراثي هو مستقر في الشغل ومتحقق اجتماعيا ً وعلاقته بالاخ جيدة (أصحاب) ويرغب في التعافي، وسوف يأخذ بروزاك 60 مجم واربيرزول 15 مجم Diagnosis/Notes Social Allergy Family History Family History No Yes Follow Up 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
