Office Visit Note
Narrative: **SUBJECTIVE:** Chief Complaint: Parental concerns regarding behavioral outbursts and aggression HPI: 13.5-year-old male with ADHD, anxiety, and borderline ASD diagnosis, history of oppositional defiant disorder diagnosed in childhood. Parents report increasing concerns about behavioral outbursts with aggressive behaviors in context of adolescent development. Currently taking guanfacine ER 2mg daily for ADHD and behavioral regulation. Actively engaged in therapy with Rachelle Hansen. **OBJECTIVE:** Telephone encounter with parents. Patient not present for examination. **ASSESSMENT:** 1. Attention-deficit/hyperactivity disorder, inadequately controlled (ICD-10: F90.9) Current guanfacine monotherapy providing insufficient behavioral regulation in context of early adolescence. 2. Anxiety disorder (ICD-10: F41.9) Contributing to behavioral dysregulation. 3. Disruptive behavior with aggression (ICD-10: R45.6) Behavioral escalation in context of ADHD, anxiety, and developmental factors. History of ODD diagnosis in childhood. **PLAN:** Medication adjustment: Increase guanfacine ER to 3mg daily for improved behavioral regulation and impulse control. Discussed risks and benefits with parents. Continue current therapy with Rachelle Hansen as behavioral component remains essential. Discussed potential augmentation strategies including aripiprazole if current adjustment does not provide adequate symptom control, reviewed rationale for atypical antipsychotic use in treatment-resistant aggression and irritability. Parents instructed to monitor response to increased dose over next 2-3 weeks. Reviewed safety planning given aggressive behaviors, emphasized importance of consistent behavioral strategies at home. Return precautions discussed including escalating aggression, suicidal ideation, or concerning behavioral changes. Follow-up telephone or office visit in 3-4 weeks to reassess response to medication adjustment. CPT: 99443 **REFERENCES:** 1. American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(1):126-141. 2. Cortese S, et al. Comparative efficacy and tolerability of medications for ADHD in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018;5(9):727-738. 3. Scotto Rosato N, et al. Guanfacine for ADHD in children and adolescents. Cochrane Database Syst Rev. 2021;2021(3):CD013196. **CODES:** CPT 99443 | ICD-10 F90.9, F41.9, R45.6 [telephone encounter with parents, patient not examined]