FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 1

Case Study: Sherman Tremaine Program Transcript

[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?

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 2

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?

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 3

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.

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 4

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]

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 1

Case Study: Sherman Tremaine Program Transcript

[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?

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 2

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?

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 3

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.

Case Study: Sherman Tremaine

© 2021 Walden University, LLC 4

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]