علم النفس الصحي
مرحبا بك
نتمني ات تجد بالمنتدي مايفيدك واذا رغبت في المشاركة فالتسجيل للمنتدي مفتوح

ولك الشكر


علم النفس الصحي
مرحبا بك
نتمني ات تجد بالمنتدي مايفيدك واذا رغبت في المشاركة فالتسجيل للمنتدي مفتوح

ولك الشكر

علم النفس الصحي
هل تريد التفاعل مع هذه المساهمة؟ كل ما عليك هو إنشاء حساب جديد ببضع خطوات أو تسجيل الدخول للمتابعة.

علم النفس الصحيدخول

الصحة النفسية علم النفس الطب النفسي


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النسخة الانجليزية

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النسخة العربية
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Patient clinical notes

Demographic data
Name
Age Sex Religion Residance
Education level Occupation
Marital status Children
Reason for referal Informant
Presenting Complain(s):..................................................................
.......................................................................................................
........................................................................................................
Histroy of present illness the story of the patient( Clarification and analysis of symptoms, precipitating and predisposing factors)
.......................................................................................................
........................................................................................................
.......................................................................................................
........................................................................................................
.......................................................................................................
........................................................................................................
.......................................................................................................
........................................................................................................
Impact of illness
.......................................................................................................
........................................................................................................
Past Psychiatric history
1st episode ......................................................................................
Onset & age of onset ......................................................................
Duration ….......................................................................................
Symptoms and diagnosis ...................................................................
Treatment& side effects .....................................................................
2nd episode ........................................................................................
..........................................................................................................
3rd episode ......................................................................................... ..........................................................................................................
Others................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
Past & present medical history
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
Alcohol and substance use history
......................................................................................................
.......................................................................................................

1
Family Study
Family structure
Name, age, occupation, education level, marital status,health
Father.............................................................................................
Mother: ...........................................................................................
Siblings:
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
Family dynamics
Realtionship between parents .............................................................
Interaction between parents and patient ...............................................
Interaction between the siblings and patient ..........................................................................................................
Family rules ...................................................................................
Communication ..............................................................................
Family history of psychiatric disorder:
1st degree relative 2nd degree 3rd degree
......................................................................................................
......................................................................................................
......................................................................................................
Home circumstances:
......................................................................................................
......................................................................................................
Socioeconomic status
......................................................................................................
Familial medical problems ......................................................................................................
Serious family events
......................................................................................................
Childhood abuse
......................................................................................................
Personal history
Psycosocial developmental history
Pregnancy..................................................................................................
Birth..........................................................................................................
Health of mother during pregnancy ..................................................................................................... .......
Early development :
Feeding: .
.....................................................................................................

2
Weaning: .........................................................................................................
Vaccination: ......................................................................................................
Childhood disease: ……………….......................................................................................................
Development milestone: .........................................................................................................................
Neurotic traits: .......................................................................................................................
Schooling:
Age………................... Type of school......................................................
Academic performance .....................................................................................................................
Social adaptation
.....................................................................................................................
Discipline ......................................................................................................
Truancy and school refusal or schooll phobia
........................................................................................................................
Work records:
Nature of job: ......................................................................................................
Performance and punctuality: ...........................................................................................................................
Stability:
.........................................................................................................................
Relationship with colleagues ........................................................................................................................
Financial income
......................................................................................................................
Previous jobs ..............................................................................................................
Psychosexual development:
Onset of Puberty ...................................................................................................... …………………
Masturbation......................................................................................................
Sexual experiences
........................................................................................................................
Sexual orientation
........................................................................................................................... nterpersonal issues ............................................................................................................................
Marital history:
Age at marriage
...........................................................................................................................
Quality of marriage
...........................................................................................................................
Sexual life
............................................................................................................................
Childern : Name Age Occupation
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
3
Relationship between parents and childern
....................................................................................................
Other issues.....................................................................................................................................................................................................
Pre – morbid personality :
Mood
....................................................................................................
Sociability
......................................................................................................
Adaptability
......................................................................................................
Hobbies
....................................................................................................
Habits
......................................................................................................
Temper
......................................................................................................
Motivation & productivity
......................................................................................................
Physical Examination
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
Mental State Examination
Appearance and behaviour...................................................................
Hygeine& dress ....................................................................................
Facial expression..................................................................................
Abnormal apperance .............................................................................
Motility Behaviour and body language
...........................................................................................................
Affect ...................................................................................................
Eye contact ..........................................................................................
Rapport................................................................................................
Catatonic features...................................................................................
Speech: amount. Volume. Relevant, any other abnormalities
......................................................................................................
......................................................................................................
Mood examination
Subjective objective
Interest& feeling of pleasure .....................energy .................
Appetite ....................body weight .................. sleep....................
Libido .................................................................................................
Psychomotor behavior ....................................................................
4
Somatic anxiety ..............................................................................
Examination of thinking
a) Shape ………..........................................................................................
b) stream .............................................................................................
c)contents :
Preoccupations .......................................................................................
Obsessional features ..............................................................................
..............................................................................................................
Overvalued ideas
..............................................................................................................
..............................................................................................................
Delusions
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
d) Possession ...................................................................................
Perception:
Sensory problems:
.............................................................................................................
Illusions
..............................................................................................................
..............................................................................................................
Hallucinations
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
Cognitive Assessment :
1.conciounsness
2.Orientation :
Time : Day Date Month Year
Passage of time ......................................................................................
Place ....................................................................................................
Persons ................................................................................................
3.Attention and concentration :
Serial7test.................................................................................................
Digit span …...............................................................................................
Spelling word .............................................................................................
Calculations ...............................................................................................
Days of the week/ months of the year .........................................................
3.Memory :
Immediate memory ...................................................................................
Recent memory .........................................................................................
Remote memory........................................................................................
Other memory problems.............................................................................
................................................................................................................
5
4.Intelligence.......................................................................................
Judgment .............................................................................................
Insight.................................................................................................

Formulation

Demographic data :
Descriptive fomulation ( chiefly / derived form HPI&MSE)
nature of onset ,duration , the course , the main psychopathological feature
..............................................................................................................
..............................................................................................................
..............................................................................................................
................................................................................................................
................................................................................................................

Differential Diagnosis :
..............................................................................................................
..............................................................................................................
..............................................................................................................
...............................................................................................................
Aetiology ( FH ,PH, Medical , Acohol & substences use )
..............................................................................................................
..............................................................................................................
..............................................................................................................
..........................................................................................................
Investigations ( Medical & Psychological)
..............................................................................................................
..............................................................................................................
..............................................................................................................
.............................................................................................................
Prognostic Factors :
..............................................................................................................
..............................................................................................................
..............................................................................................................
...............................................................................................................
Plan of management
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................






6




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