Angeles University Foundation

Department of Occupational Therapy

Occupational Therapy Evaluation in Psychosocial Dysfunctions

OCCUPATIONAL THERAPY INITIAL EVALUATION

DEMOGRAPHIC DATA
Name: Denise M. Valdez Diagnosis: Post-Traumatic Stress Disorder (PTSD)
Age/ Gender: 27/F Referring Doctor: Dr. Mark R. Santos, MD
Birthdate: October 3, 1994 Doctor’s Order: For Occupational Therapy sessions
once a week to target sleep
Address: Makati City, Metro Manila Intern-in-charge: Czarina Marie G. Roxas
Civil Status: Single Medications: Sertraline 50mg (½ tablet before
bedtime)
Sources of Information (Reliability): Client (Good Precautions: Pressured Speech (Flight of Ideas)
Reliability)
Date of Initial Evaluation: November 11, 2021 Contact Details: 0999 815 6902

Notes:
• You may begin with “Tell me something about yourself.”
• Medication – pwedeng kunin na lang sa HPI

Chief Complaint/s: (Alam nyo po ba kung bakit kayo na-refer sa OT/aming pasilidad?)
“Kapag patulog na ako, di ko mapigilan na isipin yung nangyari nung araw na yon. Akala ko talaga mamamatay na
ako. Nagfflashback tapos naiiyak ako at nanginginig sa takot. Pag naman tulog na ako, minsan napapaniginipan ko
yun at feeling ko di ako makahinga. Tapos kapag papunta akong work, iniisip ko na mangyayari ulit yun saakin.
Nagcocommute lang kasi ako tapos graveyard shift pa.”

OT Goal/s: (Dahil po ganito yung nararamdaman ninyo, ano pu yung mga gusto ninyong magawa ulit o
matutunan?)
“Gusto kong makatulog ulit ng maayos at mahimbing, kasi parang feeling ko lagi akong restless. Tapos gusto ko rin
na di ko na maisip masyado yung nangyari saakin. Nakakaapekto na rin kasi sa work ko lagi akong balisa at di
makausap ng maayos.”
• Time bound (at the moment)
• Introduce role of OT first

SUBJECTIVE FINDINGS

OCCUPATIONAL PROFILE
I. HISTORY OF PRESENT ILLNESS (Pwede nyo bang ikwento sa akin paano ito nagsimula?)
2 months prior to OT IE, the client was on her way to work around 9:00 PM for her 10:00 PM
shift. According to the client, she was in an alley on the way to her work, when a masked man pointed a
gun towards her head while asking for her wallet. She immediately gave her wallet to the man, who fled
right away afterwards. The client immediately went to the police station where she was interviewed
regarding the accident. She stated that she told the police all the details, but the police did nothing and told
her it was a normal incident in their area. The client also mentioned that when she got home, her boyfriend
said that they could not do anything about it anymore, which made the client feel invalidated.

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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions

1 month prior to OT IE, the client reported that she started having symptoms of shaking and
shortness of breath when she passed by the alley where she was robbed. She also started having difficulties
in falling asleep and nightmares which woke her up in the middle of the night. The client reported that her
boyfriend just told her to play calm music and try to sleep. They also bought over-the-counter sleeping
pills, which the client reported to be ineffective.

2 weeks prior to OT IE, the client consulted their company psychiatrist, Dr. Mark R. Santos, MD,
regarding her symptoms. After an interview and psychological testing (client could not remember the tests
done), she was diagnosed with PTSD and was prescribed Sertraline (50 mg, ½ tablet) to be taken before
bedtime.

1 week prior to OT IE, the client had a follow-up appointment with her doctor. She mentioned that
the medications were “somewhat effective”, but she still could not sleep properly. The doctor then referred
her to the company occupational therapist to help her in her difficulties.

During the OT IE, the client was on-time for the 2-hour screening and evaluation session. She was
dressed appropriately for the session, wearing her office attire. She was open and eager to answer the
therapist’s questions during the interview as she mentioned that she was comfortable with the
conversation. However, the client was manifesting pressured speech and flight of ideas when answering
the questions.

II. CONTEXT
A. Physical Context (Environmental Factors)
The client lives in a 3-storey apartment which she mentioned being situated near
Makati’s city proper. They rent a small unit with 1 bedroom, 1 bathroom, a small kitchen, and a
balcony. The client mentioned spending most of her time in the bedroom which she shares with
her boyfriend. She also mentioned a balcony where she often stays when the couple has
arguments. When asked about her comfort, the client stated that their apartment is air conditioned
and spacious enough.

B. Personal-Social Context (Personal Factors)

The client is a 27 year-old single female and full-time call center agent at a company in
Makati City. The client is currently residing with her boyfriend in an apartment they rent near the
city proper. When probed about her relationship with her parents, the client disclosed that she did
not have a good relationship with her parents and she had a bad childhood. She is the eldest among
3 female siblings. When asked about her siblings, she reported not being able to talk to them due
to interest.

Outside her family, she has a small circle of friends which she met in high school. One of
these friends being her best friend which she usually vents out her problems. But due to busy
schedules at work, she does not talk to them as much. The client is also in a relationship with her
boyfriend, whom the client has been living with for 2 years.

III. PERFORMANCE PATTERNS

A. Habits (What are your good and bad habits?)

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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions

• Dominating habits
The client often checks her back when walking alone to check if there is
somebody following her.

• Useful habits
The client meditates during her free time to alleviate stress and anxiety.

• Impoverished habits
The client spends time ruminating on the incident which causes her to feel
anxious before sleep.

B. Roles
• Employee
The client works for a BPO company as a call center agent. Her work mostly
includes taking calls and having team meetings. She describes her relationship with her
workmates as weak as they only communicate for the sole purpose of work-related
concerns.

• Daughter
The client is the eldest sibling in her family, and she was not able to fulfill her
roles and responsibilities as she left their house as soon as she graduated. She mentioned
not having a good relationship with her parents as she was always pressured to be a role
model to her siblings.

• Sister
The client is the eldest among 3 siblings. She described their relationships to be
normal for the age gap they have, but have conflicting interests which causes them to
have nothing to talk about. She also seldomly talks to them as they have their own time in
work or school. Additionally, the client mentioned that she had the least attention
growing up as she was the eldest.

• Friend
The client describes herself as an introverted person who likes having her alone
time. She described herself as someone that has only one set of friends and one best
friend.

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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions

• Girlfriend
The client is currently in a relationship with her boyfriend whom she reported to
be very supportive in her family and work problems.

C. Routines
The client’s routine usually starts at 2:00 PM as she works a graveyard shift. She
mentioned having her own pace and timing at home during the afternoon. She mentioned having
an exact routine for her self-care and household chores. However, her condition has greatly
affected her sleep routine as compared to prior to the incident where she sleeps at a set time frame.
The client’s work schedule is from 10:00 PM to 7:00 AM and has a 1 hour break at 2:00 AM. As
her shift ends, she usually heads home to sleep.

The client usually does her household chores everyday so that she can have rest during
the weekends. She values her time spent on things she needs to do as she believes that time is very
important.

Time Pre-Morbid Time Post-Morbid Level of

Assistance

2:00 PM Wake-up, self-care, 2:00 PM Wake-up, self-care, Independent

prepare food, eat prepare food, eat

3:00 PM - Household Chores/ 3:00 PM - Household Chores/ Independent

4:30 PM Errands 4:30 PM Errands

4:30 PM - Rest 4:30 PM - Rest Independent

5:00 PM 5:00 PM

5:00 PM - Prepare dinner for 5:00 PM - Prepare dinner for Independent

6:00 PM boyfriend 6:00 PM boyfriend

6:00 PM - Dinner 6:00 PM - Dinner Independent

7:00 PM 7:00 PM

7:00 PM - Wash dishes, clean kitchen 7:00 PM - Wash dishes, clean kitchen Independent
7:30 PM 7:30 PM

7:30 PM - Rest 7:30 PM - Meditate Independent

8:30 PM 8:00 PM

8:30 PM - Prepare for work 8:00 PM - Prepare for work Independent

9:30 PM 9:00 PM

9:30 PM - Travel to work 9:00 PM - Travel to work Independent

10:00 PM 10:00 PM

10:00 PM - Work 10:00 PM - Work Independent

2:00 AM 2:00 AM

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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions

2:00 AM - Break 2:00 AM - Break Independent

3:00 AM 3:00 AM

3:00 AM - Work 3:00 AM - Work Independent

7:00 AM 7:00 AM

7:00 AM - Go home 7:00 AM - Go home Independent

7:30 AM 7:30 AM

7:30 AM - Sleep 8:30 AM - Sleep Independent

2:00 PM 2:00 PM

D. Rituals
The client usually does her household chores everyday so that she can have rest during
the weekends. She values her time spent on things she needs to do as she believes that time is very
important.

IV. CLIENT FACTORS

A. Values
The client values spending time with her boyfriend and family most especially during
weekdays. She plans and sets a schedule of activities throughout the day where they can bond all
together.

B. Beliefs
The client believes that she must plan and follow her routine to ensure productivity
throughout the day.

C. Spirituality
The client attends monthly church meetings that involve reflections of faith and
improvement of relationship with God and other people.

OBJECTIVE FINDINGS
I. Standardized Test Results
A. Pittsburgh Sleep Quality Index (PSQI)
The PSQI was used to assess the overall sleep quality of the client. It evaluates sleep
behavior, difficulty, and quality over the course of the past month or 30 days. The client garnered
a Global PSQI score of 15 out of 21, which indicates that the client has poor sleep quality with
problems in sleep preparation and participation. Component scores and remarks are listed on the
table below:

Component Score Remarks

1. Subjective sleep quality 2 The client’s subjective sleep quality is fairly bad.
The client’s sleep latency is affected when the client is
2. Sleep latency 3 experiencing anxiety which takes her longer to fall
asleep.
The client’s sleep duration is 5-6 hours which is
3. Sleep duration 2
slightly below the recommended time of sleep.

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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions
4. Sleep efficiency
5. Sleep disturbance
6. Use of sleep medication
7. Daytime dysfunction
Global PSI Score:
*See Appendix A for full PSQI Assessment*
II. Analysis of Occupational Performance
Occupation 1
Sleep Participation
Steps/ Tasks Involved
Achieved/Not achieved
1. Preparing for bed (turning
off lights, making the bed,
etc.)
2. Lying down on the bed
3. Finding a comfortable
position
4. Closing eyes
5. Clearing thoughts
Achieved but Needs
6. Falling asleep
Improvement
Documented by:
Name and Signature of OT Student
Student no.
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The client’s sleep efficiency is calculated to be at 86%
0
which is good.
The client’s notable sleep disturbances are trouble
breathing, nightmares, and waking up in the middle of
2
sleep. Having to use the bathroom and snoring came in
second to her sleep disturbances.
The client used over-the-counter sleeping pills, which
3
she described as ineffective.
The client has notable problems in keeping enthusiasm
3 throughout the day and somewhat of a problem in
keeping herself awake during daytime activities.
The Global PSQI Score is 15 out of 21, which indicates
that the client has a poor quality of sleep, since the
15
higher the score, the more it equates to a poor sleep
quality.
Status Performance Capacity
(Performance skills involved)
Aligns – the client aligns the body with
the task object.
Reaches – the client reaches for the task
Achieved
object.
Manipulates – the client manipulates the
task object.
Stabilizes – the client stabilizes the body
to prepare to lie down.
Achieved
Aligns – the client aligns the body to the
bed.
Positions – the client positions the body
Achieved
on the bed.
Chooses – the client chooses a time to
Achieved
close eyes.
Adjusts – the client adjusts to clear
thoughts in preparation for sleep.
Not Achieved
Continues – the client continues to try to
sleep.
Initiates – the client initiates sleeping.
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Angeles University Foundation
Department of Occupational Therapy
Occupational Therapy Evaluation in Psychosocial Dysfunctions

Appendix A

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