NU 613/ NU613 SB Soap Note: SB is a 38 year-old male who presents with a history of depression, anxiety, adhd and alcohol abuse in remission. | Answered.

Patient: SB DOB: 5/28/1985 Sex: M
Encounter Date: 05/16/2025
Encounter Type: Follow up Outpatient




SUBJECTIVE:

Chief Complaint:
SB is a 38 year-old male who presents with a
history of depression, anxiety, adhd and alcohol
abuse in remission.

History Of Present Illness:
"I'm markedly better"
- Rates depression 4-5/10. Depression is improved.
"Always present but better"
- Anxiety is 3/10 "I haven't had much anxiety
lately"
- Working full-time as an attorney. Feels good back
at work and in routine.
- Feels work routine is manageable and keeping his
mood stable without time to be depressed or
overthink.
- Denies suicidal thoughts
- Denies homicidal thoughts plans or intent.
- Denies side effects of medications.
Overall progress: significantly improved / stable

Current Medications:
- Effexor 150 mg
- Vraylar 1.5 mg

Medications prescribed by PCP:
- Metoprolol 50 mg once daily for Hypertension
- Effexor 75 mg once daily (for 5 years) - tried to
discontinue 3 months ago - had citalopram adjunct.
- 0.5mg Xanax PRN for anxiety (taking 2x per day
for the past year)
- Adderall 30 mg bid
- Medications currently prescribed by Primary Care
Provider (PCP)