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]