Marcus A. Johnson
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II Wk. 5 Focused SOAP Note Sherman
Tremain
Dr. Amanda Porter
9/29/24
, CC: CC (chief complaint): His neighbors are watching him, and he hears music and voices. He
also says that he fears for his life and that his sister is conspiring with the government. His sister
forced him to go to his appointment, and these symptoms have persisted for several weeks.
HPI: Sherman Tremaine, a 55-year-old man, has been under constant surveillance from people
outside his window for the last couple of weeks. He also claims that the government is poisoning
his food and that the grocery store and television are conspiring against him. The voices that he
reportedly hears constantly cause his sleep problems.
Past Psychiatric History:
Hospitalizations: pt states being hospitalized three times when he about 20 years old.
Symptoms: Paranoia, auditory and visual hallucinations, and delusional thinking, including
thoughts about being watched by the government and people outside his window.
Sleep Issues: pt Reports trouble sleeping due to disturbing voices.
Family Psychiatric history: pt reports his father was diagnosed with paranoid schizophrenia and
was hospitalized in the old state hospital.
Substance Current Use: Three packs of cigarettes are consumed every day. a 12-pack of
alcohol/week and stopped using marijuana three years ago when my mother died.
Medical History: Multiple admissions to a Psychiatric hospital at approximately age 20. fatty
liver, diabetes, currently taking metformin.
Current Medications: Metformin for diabetes
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II Wk. 5 Focused SOAP Note Sherman
Tremain
Dr. Amanda Porter
9/29/24
, CC: CC (chief complaint): His neighbors are watching him, and he hears music and voices. He
also says that he fears for his life and that his sister is conspiring with the government. His sister
forced him to go to his appointment, and these symptoms have persisted for several weeks.
HPI: Sherman Tremaine, a 55-year-old man, has been under constant surveillance from people
outside his window for the last couple of weeks. He also claims that the government is poisoning
his food and that the grocery store and television are conspiring against him. The voices that he
reportedly hears constantly cause his sleep problems.
Past Psychiatric History:
Hospitalizations: pt states being hospitalized three times when he about 20 years old.
Symptoms: Paranoia, auditory and visual hallucinations, and delusional thinking, including
thoughts about being watched by the government and people outside his window.
Sleep Issues: pt Reports trouble sleeping due to disturbing voices.
Family Psychiatric history: pt reports his father was diagnosed with paranoid schizophrenia and
was hospitalized in the old state hospital.
Substance Current Use: Three packs of cigarettes are consumed every day. a 12-pack of
alcohol/week and stopped using marijuana three years ago when my mother died.
Medical History: Multiple admissions to a Psychiatric hospital at approximately age 20. fatty
liver, diabetes, currently taking metformin.
Current Medications: Metformin for diabetes
