Professional Documents
Culture Documents
OTIE - Vince Lucido
OTIE - Vince Lucido
I. Occupational Profile
“Minsan pag tinatawag, hindi lumilingon.” [improve work behaviors to be able to follow
commands]
“Di pa nagsasalita. More on no and hindi lang
sinasabi. Maingay pero di naiintindihan sinasabi.”
The said observations were reported to his pediatrician, Dr. Pamintuan. The doctor recommended to wait
for further observations before referring to a neurodevelopmental pediatrician since Vince is too young.
His mother decided that Vince should receive occupational therapy services while waiting for an
appointment to a neurodevelopmental pediatrician. This is Vince’s first time to receive occupational
therapy services.
B. Contexts
1. Home
Vince’s lives with his mother, grandmother and ate. He is mostly left with his grandmother or ate
since his mother works at their store. His father is a soldier and is currently based in Tawi-Tawi. He
goes home around 3-4 times a year.
Vince’s routine at home is generally unstructured. It is comprised mostly of self-care tasks such as
feeding, bathing, etc. as well as play activities. He likes playing with cars, fruits and vegetables, and
animals. When playing with toys, he would usually hold them in pairs and puts them repeatedly. He
was also observed to bang them on surfaces that make sound. The use of gadgets has been greatly
decreased. He only listens to nursery rhymes using a radio.
2. School
Vince currently does not attend any form of schooling. Additionally, it is still not expected for his age.
In terms of the tactile system, he may exhibit tactile over responsiveness to certain textures.
As observed, he was apprehensive when touching slimy textures such as glue and clay, but
can tolerate rough textures such as sand. This is also reported through avoiding activities such
as haircutting.
In terms of the auditory system, he may also exhibit auditory over responsiveness. He was
reported by his mother to cry when hearing loud noises such as fireworks and changes in
volume of voice.
With this, Vince should be provided with play activities that would facilitate organization of his
systems. This will be done through exposing him to different sensory experiences during
therapy sessions. Addressing these sensory processing difficulties will assist him in his
occupational performance.
GRADE REMARKS
RGCR F Upon evaluation, Vince was noted to have difficulty in releasing toys when
transferring. He had difficulty with performing voluntary release.
Grip strength F Vince was observed to release grasp on squigz after a few seconds when
attempting to remove them from the glass surface.
Pinch strength P He was observed to have difficulty in obtaining small animal pieces from
theraputty.
GROSS PREHENSION PATTERNS
Cylindrical G Vince was able to assume, maintain and use cylindrical grasp in holding a
bottle.
Hook G Vince was able to assume, maintain and use hook grasp in holding the basket
handle to carry it.
Spherical G Vince was able to assume, maintain and use spherical grasp in getting balls.
FINE PREHENSION PATTERNS
Lateral Vince was able to assume a lateral pinch in getting formboard pieces but
F noted difficulty in maintaining and using it.
Pad-to-pad Vince was able to assume a pad-to-pad pinch in getting formboard pieces
but noted difficulty in maintaining and using it.
Tip-to-tip P Vince needed hand-over-hand assistance in transferring small pegs using a
tip-to-tip pinch
Three jaw chuck P Vince needed physical assistance to assume, maintain and use a three jaw
chuck grasp in opening clothespins.
WRITING SKILLS
Pencil grasp AA Palmar supinate
Hand preference Left
IN-HAND MANIPULATION
Finger-to-palm F Vince was able to get coins from the table and transfer it to his hand with
translation some instances of dropping noted.
COORDINATION
Eye-hand F He is able to shoot shapes inside wooden peg shape sorter but with
coordination occasional difficulty in putting the hole towards the wooden peg.
Arm-hand G He is able to shoot rings and stack them independently with no undershooting
coordination or overshooting noted.
BILATERAL COORDINATION
Symmetrical G No noted difficulty in pushing the basket presented to him.
Asymmetrical F Physical assistance was needed for him to stabilize the fruit using one hand,
as he slices with the other
Reciprocal F Vince showed some difficulty in coordinating his hands and feet with
alternating movements such as when climbing up the stairs of the slide
o Listening skills
Vince was observed to have poor auditory processing skills as reported with his poor response
to name calling. Additionally, no response was noted when he was verbally instructed to give
and put back the toy presented to him.
o Communication skills
Vince’s expressive language skills are limited to one-word utterances such as “no” and “hindi”
only. Other verbalizations are rarely noted. In terms of receptive language skills, he was
observed to be unable to follow commands such as “sit down”, “stand up”, and “high five”.
o Cognitive skills
Vince has limited knowledge of concepts in such as colors and shapes. However, he is able
to use ADL objects that he uses regularly.
o Work behaviors
*G – good, F- fair, P- poor
WORK BEHAVIOR GRADE REMARKS
Attention Span P Vince exhibited poor attention span lasting for ~1 minutes during
non-preferred task such as matching a formboard piece and around
~2 minutes for preferred tasks such as letting him play with a toy of
his choosing.
Concentration P Vince has poor concentration as he is easily distracted with visual
and auditory stimuli around the environment such as the presence
of several toys in the mat area and other sounds such as a kid crying.
Impulse Control F Vince showed fair impulse control, with instances of grabbing toys
on his immediate vicinity. This may be typical of his age.
Frustration Tolerance P Vince showed poor frustration tolerance often crying or disengaging
from a task that he cannot perform.
Sitting Span F Vince requires physical prompts to remain seated on chair during
table-top activities. This may be typical of his age.
Following instructions P Poor compliance was noted during the evaluation session as he was
noted to have (+) stranger anxiety.
III. Analysis of the transaction between factors: performance (functions and skills), roles, routines,
and environment
IV. Plan
Recommendations:
Report prepared by:
Nina Karmela V. Garcia, OTRP
Occupational Therapy Consultant
PRC License No. 003537
Should you have any question regarding this document, do not hesitate to contact
the undersigned at mobile number 0917 829 2985 or e-mail at
nkvgarcia@gmail.com.