Office Visit Note
Narrative: Subjective • Chief Complaint: Mood concerns, follow-up for depression/anxiety and behavioral regulation. • HPI: Parent reports child “seems a little slowed down” since starting sertraline 75 mg daily. No reported side effects from guanfacine BID. Ongoing difficulty with anger and irritability, though summer schedule is less structured, which may be contributing. No acute safety concerns expressed. Will be starting with therapist Rachelle Hansen after the 4th of July. Objective • Vitals: [not documented] • Exam: Well-appearing, interactive, appropriate affect. No abnormal movements. Speech fluent. Mood somewhat irritable per report, but behavior appropriate in visit. Heart and lungs clear, abdomen soft, no focal neuro findings. Assessment 1. Depression/anxiety, on SSRI (F32.89/F41.9, Z79.899) – on sertraline 75 mg, mild sedation reported, otherwise tolerated. 2. ADHD/behavioral dysregulation (F90.9) – on guanfacine BID, tolerated without notable side effects. 3. Anger/irritability, chronic (R45.4) – persisting, possibly exacerbated by lack of school structure. Plan • Continue sertraline 75 mg daily through start of therapy. Will reassess efficacy and tolerability after therapy initiation. • Continue guanfacine BID, no adverse effects noted. • Supportive counseling provided; encouraged parents to monitor mood, anger outbursts, and daily functioning. • Starting therapy with Rachelle Hansen in early July – anticipate improved behavioral support. • Return/Call sooner for worsening mood, emergence of suicidal thoughts, significant side effects, or behavioral escalation. • Follow up in clinic after therapy has begun for medication/behavioral reassessment. Footer • CPT: 99213 (established, med management) • ICD-10: F32.89, F41.9, F90.9, R45.4, Z79.899 Orders Orders