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 ولاء سيدة عمرها 47 سنة، الكبري لثلاث بنات، الاب توفي من 19 سنة وكان تربوي، الام مصرفية وتوفيت 2020، وهي خريجة تجارة ولا تعمل ولم تتزوج، وتعيش مع اخت غير متزوجة واخت مطلقة، وقد بدأت العلاج النفسي في عمر 27 سنة وذلك مع مرض الاب بسبب نقص النوم والاكتئاب وعدم الانبساط واستمرت مع محمد طه عشر سنوات ثم محمد غانم عشر سنوات ثم جاءت لي وقد شخصت اكتئاب فقط، وحاليا ً علي ريميرون ولوسترال وكويتابكس وترايليبتال وسوليان ولا تتحسن وتقضي وقتها في شغل البيت ومساعدة الاخوات، وزهقانة جدا ً جدا ً وكذلك الاخت المطلقة زوجها لا يساعدها والاخت الغير متزوجة مريضة اغلب الوقت وكل شوية لا تعمل، عايشة علي معاش الاب والام، وهي سيدة غريبة لأنها عاشت طول عمرها منعزلة ووحيدة ولا تعمل وغير متزوجة ومكتئبة وشايفة ان ذلك بسبب الحسد من الاقارب؟! ولكنها ليست سكيزوتاتبال وربما ليست اضطراب شخصية والاعراض الحالية، الوحدة، الخمول، قلة المزاج، والتقلب المزاجي، فقدان الاهتمام، الارق والنوم المتقطع، اليأس، صعوبة التركيز، التوتر، سهولة الانفعال والزهق وانها شايلة اختها المتزوجة وزوجها وكل شوية، وتشخيصها اكتئاب مزمن وحاليا ً علي تراليبتال واضيف افيكسور واشوفها كمان شهر ونص لتقييم العلاج والبدء بالعلاج النفسي 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
