PSYCHIATRIC EVALUATION

I. PSYCHIATRIC HISTORY
A. Identification
The patients name is Rommel Olazo, Filipino male, born on the day of May 27, 1970, who is 44
years old and lives at 566 San Roques, San Pedro Laguna. He was separated with his wife and has 2
kids, one girl and one boy. According to him, he doesnt have work. Hes religion is Born Again. He also
speaks more of Tagalog than English.

B. Chief Complaint

The patient was asked by the therapist if there are things that make it hard for him. The patient
verbally said wala, wala naming nagpapahirap saakin. In short the patient doesnt have any chief
complaint.

C. History of present illness

The patient has been addicted to drugs before when he was 28 yrs old and it took him 4 yrs to be
addicted. He was started to use drugs because of his co-workers, he was been influenced and he
decided to stop his addiction because he felt difficulty in sleeping and because of that his mood became
angry and elevated as higher as if hes always mad. He also experiencing headaches when taking Shabu
his mood changes and became irritable almost every day so he decided to stop.

D. Past psychiatric and medical history

According to the patient, he was rushed in to the hospital in Amante San Pedro Laguna because
he was hit on head then he experienced to stitch his head by the doctor then he went home already. He
verbally said naku nasugod ako sa amante sa may san pedro kasi binato ko ng kalaro ko nung bote sa
ulo taspos suinugod na ko sa hospital para tahini He also added that he didnt stayed longer in the
hospital, he immediately went home. He didnt felt any effect on his brain or head after what happened to
him. He also added that, recently hes been experiencing hearing loud noises especially in night time and
didnt know where it came from or no idea. He also experiencing minor problems in his eyes, when he see
things he thinks it was doubled or two even blurred vision, so then he was finding hard time to know what
is real when he was about to see things clearly.

E. Family history

Mr. Olazo stated that he only experienced minor sickness and those are, fever, headache and
sprain on his right foot because of playing hospital. He also experiencing blurredness on his both eyes but
he didnt have enough money to go to ENT clinic to have check-up.

According to Mr. Olazo he had vices like, drinking sometimes only if his cousins are there drinking
too and smoking and using more than 2 pack of cigarettes within a month. He was 36 years old when he
started to use those vices. When he was asked how kind of family he has he stated that its only simple
and he stated her parents name. Her mother named is Teresita Olazo and his father is Jose Ulazo Sr.
They are 3 siblings, his older sister died since the bornday and hes the second and the third one is 44 yrs
old, most of the time they fight because of being hard headed of his brother but he only do it just for an
advice.

After that he was asked how he can described his father he stated that her father has thick hair
brows, has white hair and kind but angry at times. He even experienced hit by his father with a belt and

his mother was there to stop his father while hitting him. So he described her mother having white skin,
chinita eyes, black hair and very kind mother. He stated that her mother never stopped taking care of
them. According to Mr Olazo when he was 39 yrs old, his father died because of gunshot, he felt sadness.
When he was asked how he forget the pain, he said verbally Hindi ko nalang iniisip ung nangyari sa tatay
ko. Gumawa ako ng kung ano anong bagay, naglibang ako. He also stated that among his family, he and
his father has the same attitude and how the way he gets mad.

F. Personal and Social history

CHILDHOOD:

When he was a child the most unforgettable thing was they lived near cockpit place or coliseum,
he played near that place. He also played tanstsing outside their house. According to him, he started
schooling when he was 7 yrs old and entered as kinder. He felt shy when he entered school because it
was his first time, he was always accompanied by his mother. He never cry when her mother leave her in
his school unlike other children. He was thin and dark child that time. He was a caesarian baby. When he
was asked about having a best friend, he answered that he doesnt have any but he has friends, only
close friends and he consider his cousins as her friends also.

ADOLESCENT:

When he reached being an adolescent, the first medal he ever received was when he joined in
basketball league. He finished high school and doesnt have any plan to take college because for him its
very long until he got work, so after he graduated from high school he straight ahead to apply work on
pabrika which is his dream work after high school. His hobbies are playing basketball and playing pusoy
dos, lucky 9 with his cousins. He added that his adolescent life was just simple and enjoyable.

ADULTHOOD:

Adulthood led him to some strange happenings in his life. He had wife named Nerissa and they
met from friends of friends they had 2 children 1 boy and 1 girl both are living in Tarlac with his wife
because they separated. It happened because he resigned to his work, the reason of his resigning was
he was influenced by his co-workers to used shabu until then he was used to it and never stopped for 4
years. He said that it started when he was 28 yrs old. When he felt that hes having difficulty in breathing,
he decided to stop. When he was asked if he was been in rehab, he said that hes never been there. He
only did was self-medication by going to center of their barangay.

II. MENTAL STATUS

The patient appears to be awake and alert during the interview. Sometimes, because of prolong
siting he tends to slouched or slumped. His mannerism are squeezing his both hands and rocking his
both legs while his feet are on the floor. Mr.Olazo tends to face the ceiling before he answer or give
feedback to the questions given by the interviewer.
Mr. Olazo is dressed appropriately. His hair is kempt and looks good. His overall appearance
suits to his age. He has normal gait for short there are no leg discrepancies. He manifest thinking during
the interview and does not speak spontaneously. Mr. Olazo stuttering most of the time, his tone of voice
was very soft. The patient is monotone and has low volubility of voice. He shows non spontaneous
speech where verbal response given only when asked. Whenever he talks about his life like happy
moments, he was able to show appropriate emotions. Mr. Olazos mood was looking terrified and he can
even relate his mood to what and how he tell the story.

The patient was able to speak spontaneously only when questions asked. Mr. Olazo was able to
answer questions based on relevant answer and connected to the questions being asked. There are no
signs of language impairments. During the interview he did not manifest any thought of disturbances or

perpetual disturbances but when he was asked if hes been experiencing it, according to Mr. Olazo, he
heard noises at night which is a signs and symptoms of auditory hallucination. It was hard for him to sleep
at night because of hearing noises.

Mr. Olazo was aware where he was and there are no signs and symptoms being describe. He
was cooperative and shows interest to answer the questions. Mr. Olazo identifies the time by answering
the question of the therapist what time is it. He was able to answer where he was and what is the
purpose why hes here. His answers are and it was verbally said Dito sa Perpetual Binan, iinterview daw
ako. According to the patient, he forgot the names of the person when he came back for the second part
of the interview. The therapists was able to introduce their names but unfortunately the patient cant recall
their names. Maybe because they are 3 person evaluating him.

The therapists asked questions related to mathematics and the good thing is that the patient
answered all of it. In terms of concentration he was able to manage it and there are no signs of mood
disturbances when calculating. The patient shows good memory where he was able to remember all
every details of the story of his remote, recent and immediate memory but sometimes he was thinking
long before to answer the questions.

The level of education of Mr. Olazo on how he thinks and have concrete and abstract thinking
was capable of functioning and based on his age on how the thinks. He wasnt able to take college but on
how he calculate, count and even general knowledge he was able to answer it and has good level of
intellectual capability.

The patient has good abstract thinking, where he answers the questions

appropriately like he was able to think abstractly of the phrase Time is Gold he answered verbally the
time is very precious that we should not waste any time of it the second question was based also about
the phrase Pag may tyaga may nilaga then he answered pag may sipag ka, may makakain ka at may
pera ka and the last question about phrases was Aanhin pa ang damo kung patay na ang kabayo? and
he answered Aanhin mo pa kung wala ng pagbibigyan there are also questions asked about comparison
and differences of things or concrete questions like what is the difference of airplane and bird he said that

the plane has machine and gasoline to fly but the bird has its wings to fly. All in all he was good and has
capability in terms of abstract thinking. The patient does not appear that hes aware of his condition he
thinks hes healthy and living normal with those loud noises he heard and he has psychiatric condition.

The patient has good judgment in terms of giving questions on how he would do in imaginary
situations like Ano pong gagawin nyo pag may aleng tumawid he then said, he will help and accompany
the old woman in passing the way and he was also asked what he will do if his neighbors house is
burning? He said that he will help to clear the fire and last question that the therapist conducted was hes
opinion about abortion, he know that it is bad to abort a child because it means of disrespectful to the
Lord as a sin and lastly killing the life of child is not good.

III. FURTHER DIAGNOSTIC STUDIES

None

IV. SUMMARY OF FINDINGS

The patient appears to be awake and alert during the interview. Mr. Olazo is dressed
appropriately. His hair is kempt and looks good. He seemed to be relaxed and ease for the whole
interview. Sometimes, because of prolong siting he tends to slouched or slumped. His mannerism are
squeezing his both hands and rocking his both legs while his feet are on the floor. His overall appearance
suits to his age. He has normal gait for short there are no leg discrepancies. He manifest thinking during
the interview and does not speak spontaneously. Mr. Olazo stuttering most of the time, his tone of voice
was very soft. The patient is monotone and has low volubility of voice. He shows non spontaneous
speech where verbal response given only when asked.

V. DIAGNOSIS
Axis I. 292.12 Amphetamine induced psychotic disorder with hallucinations
Axis II. 301.22 Schizoid Personality Disorder
Axis III. V61. 9 Head injury
Axis IV. V61.10 Divorced; Death of father
Axis V. Global assessment functioning = 61 Moderate symptoms (e.g., flat affect and
circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school
functioning (e.g., few friends, conflicts with peers or co-workers).

VI. DIFFERENTIAL DIAGNOSIS

1. Depressive Disorder NOS
2. Cyclothymic Disorder
3. Bipolar Disorder NOS
4. Schizophrenia
5. Psychotic Disorder

____________________________
Gonzales Rizalyn S.
09169513982
Occupational Therapy Student