FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. P

[MUSIC PLAYING] DR. MOORE: Good afternoon. I'm Dr. Moore. Want to thank you for coming

in for your appointment today. I'm going to be asking you some

questions about your history and some symptoms. And to get started,

I just want to ensure I have the right

patient and chart. So can you tell me your

name and your date of birth? SHERMAN TREMAINE:

I'm Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968. DR. MOORE: Great. And can you tell

me today's date? Like the day of the week,

and where we are today? SHERMAN TREMAINE: Use any recent

date, and any location is OK. DR. MOORE: OK, Sherman. What about do you know

what month this is? SHERMAN TREMAINE: It's March 18. DR. MOORE: And the

day of the week? SHERMAN TREMAINE: Oh, it's a

Wednesday or maybe a Thursday. DR. MOORE: OK. And where are we today? SHERMAN TREMAINE:

I believe we're in your office, Dr. Moore. DR. MOORE: OK, great. So tell me a little bit about

what brings you in today. What brings you here? SHERMAN TREMAINE: Well,

my sister made me come in. I was living with my

mom, and she died. I was living, and not bothering

anyone, and those people-- those people, they just

won't leave me alone. DR. MOORE: What people? SHERMAN TREMAINE: The ones

outside my window watching. They watch me. I can hear them, and

I see their shadows. They think I don't

see them, but I do. The government sent

them to watch me, so my taxes are high,

so high in the sky. Do you see that bird? DR. MOORE: Sherman,

how long have you saw or heard these people? SHERMAN TREMAINE: Oh, for weeks,

weeks and weeks and weeks. Hear that-- hear that

heavy metal music? They want you to think

it's weak, but it's heavy. DR. MOORE: No, Sherman. I don't see any birds

or hear any music. Do you sleep well, Sherman? SHERMAN TREMAINE: I try to

but the voices are loud. They keep me up

for days and days. I try to watch TV, but they

watch me through the screen, and they come in

and poison my food. I tricked them though. I tricked them. I locked everything

up in the fridge. They aren't getting in there. Can I smoke? DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke? SHERMAN TREMAINE: Well,

I smoke all day, all day. Three packs a day. DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack,

and tells me to make it last until next week's grocery run. I don't go to the grocery store. They play too loud of

the heavy metal music. They also follow me there. DR. MOORE: What about marijuana? SHERMAN TREMAINE: Yes,

but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No,

no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about

any blackouts or seizures or see or hear things

from drugs or alcohol? SHERMAN TREMAINE: No, no, never

a clever [INAUDIBLE] ever. DR. MOORE: What about

any DUIs or legal issues from drugs or alcohol? SHERMAN TREMAINE:

Never clever's ever. DR. MOORE: OK. What about any medication

for your mental health? Have you tried those before, and

what was your reaction to them? SHERMAN TREMAINE: I hate

Haldol and Thorazine. No, no, I'm not

going to take it. Risperidone gave me boobs. No, I'm not going to take it. Seroquel, that is OK. But they're all poison,

nope, not going to take it. DR. MOORE: OK. So tell me, any

blood relatives have any mental health or

substance abuse issues? SHERMAN TREMAINE:

They say that my dad was crazy with

paranoid schizophrenia. He did in the old

state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood

relatives commit suicide? SHERMAN TREMAINE:

Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything

like cut yourself, or had any thoughts about killing

yourself or anyone else? SHERMAN TREMAINE:

I already told you. No demons there. Have been in the hospital three

times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any

medical problems? SHERMAN TREMAINE: Ooh, I

take metformin for diabetes. Had or I have a fatty

liver, they say, but they never saw it. So I don't know unless

the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My

mom and my sister. DR. MOORE: And who

do you live with now? SHERMAN TREMAINE:

Myself, but my sister's plotting with the

government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,

widowed, or divorced? SHERMAN TREMAINE: I've

never been married. DR. MOORE: Do you

have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest

level of education? SHERMAN TREMAINE: I

went to the 10th grade. DR. MOORE: And what do

you like to do for fun? SHERMAN TREMAINE: I don't work,

so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or

convicted for anything legally? SHERMAN TREMAINE: No, but

they have told me they would. They have told me they would

if I didn't stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma

as a child or an adult? Like physical, sexual,

emotional abuse. SHERMAN TREMAINE: My dad was

rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering

those questions for me. Now, let's talk about

how I can best help you. [MUSIC PLAYING]