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Below is the reformatted clinical note based strictly on the provided information:

Patient Information

• Name: Alicia Blanks
• Age: 26 years old
• Gender: Female
• Date of Service: 11/5/2024
• Provider: Michael McDowell (Specialty Code: 394800008)
• Place of Service: Office (11)
• Visit Type: Established Patient
• Telehealth: No

Chief Complaint Patient presents for evaluation of attention/concentration difficulties and is requesting neuropsychological testing and genetic testing.

History of Present Illness (HPI)

• Narrative:
  The patient reports longstanding symptoms consistent with attention-deficit/hyperactivity disorder (ADHD) that have worsened amid significant occupational stress. She describes herself as a "squirrel type person" with chronic distractibility dating back to childhood. Previously, she managed symptoms with physical activity; however, current knee problems limit this coping strategy. The recent exacerbation of symptoms is attributed to increased responsibilities in a supervisory management position and ongoing harassment from a problematic employee. The harassment includes persistent defamation and multiple complaints to agencies such as the Department of Labor and the Department of Justice, resulting in heightened stress and feelings of being "broken."

• Additional Details:

  • Onset/Duration: Symptoms have been longstanding since childhood but notably worsened over the past year with her new supervisory role.
  • Aggravating Factors:
    • Occupational stress, including persistent harassment at work
    • Inability to utilize previous coping mechanisms due to physical limitations
  • Symptom Description:
    • Difficulty with attention span and organization
    • Easily distracted, extreme agitation, and feeling scattered
    • Requires lists and calendar systems to maintain organization
    • Significant emotional impact with feelings of hatred toward the problematic employee
  • Associated Features:
    • Sleep disturbances (waking every hour through the night)
    • Decreased appetite
    • Difficulty with cortisol regulation affecting weight management
    • Hypervigilance and difficulty relaxing

Past Medical History (PMH)

• Psychiatric History:

  • No prior psychiatric treatment or medication.
  • No previous ADHD diagnosis or formal evaluation despite longstanding symptoms.
  • Family history indicated resistance to any mental health medications during childhood.

• Social History:

  • Background in psychology with law school attendance in Michigan.
  • Currently employed as a government employee in a supervisory/management role with remote work status.
  • Resides in the Yorkville area and is a mother to a daughter.

Review of Systems (ROS)

• Sleep: Waking every hour through the night
• Appetite: Decreased (not really hungry)
• Psychiatric:
  • Difficulty with attention/concentration
  • Increased hypervigilance
  • Irritability
  • Difficulty relaxing

Physical Examination (Note: Formal vital signs were not documented.)

• Mental Status Examination:

  • Appearance: Not formally documented
  • Behavior: Talkative and engaged; noted surprise at amount of talking
  • Speech: Rapid, sometimes tangential, and with a pressured quality
  • Mood: Stressed and agitated per patient report
  • Affect: Appropriate to content, animated
  • Thought Process: Goal-directed with occasional tangentiality; no loosening of associations
  • Thought Content: Preoccupied with occupational stressor; no suicidal or homicidal ideation documented
  • Cognition: Alert and oriented
  • Insight/Judgment: Good insight into symptoms and situation

• ADHD Screening Assessment:
  The provider administered an ADHD screening questionnaire with the following findings:

  Inattention Symptoms:

  • Difficulty wrapping up final details of tasks
  • Problems getting organized (relies on lists/calendar systems)
  • Forgetfulness regarding appointments or obligations
  • Procrastination on tasks requiring intense thought
  • Careless mistakes on boring or challenging projects
  • Difficulty sustaining attention on repetitive work
  • Occasional problems concentrating on conversation
  • Tendency to misplace or have difficulty finding things
  • Easily distracted by environmental activity or noise

  Hyperactivity/Impulsivity Symptoms:

  • Fidgeting and squirming
  • Feeling overly active with a constant need to move (uses exercise equipment during work)
  • Leaving her seat in meetings when expected to remain seated
  • Difficulty unwinding during free time

  Screening Conclusion:
  The preliminary screening tool indicated symptoms consistent with adult ADHD, with a notably high score.

Assessment / Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation:

   • Clinical reasoning based on longstanding history of inattention, distractibility, hyperactivity, and organizational difficulties, now exacerbated by occupational stress.

2. Occupational Stress/Adjustment Disorder:

   • Significant workplace harassment leading to sleep disturbance, decreased appetite, hypervigilance, and difficulty relaxing. The patient reports feelings of being overwhelmed without organizational support.

3. Sleep Disturbance:

   • Likely secondary to anxiety/stress related to the chronic and exacerbated occupational challenges.

Differential Considerations:
The provider discussed that the symptoms might also be influenced by severe anxiety triggering brain fog. If anxiety is the primary driver, stimulant medications could potentially worsen her anxiety.

Plan / Treatment

1. Pharmacogenomic Testing:

   • Buccal swab collected today for pharmacogenomic testing to aid in medication guidance.
   • Results expected within approximately one week.
   • Patient provided information regarding accessing the results online.

2. Medication Trial:

   • Initiated trial of Concerta (methylphenidate extended-release) 27 mg.
   • Rationale: 27 mg chosen as an appropriate starting dose for adults instead of the typical 18 mg dose.
   • Extended-release formulation selected to minimize midday dosing and to provide a steady effect over 8-10 hours.
   • Prescription sent to Costco Naperville Route 59 pharmacy.

3. Patient Education – Medication:

   • Reviewed potential side effects: heavy caffeination initially, headache, dizziness, racing heart (with rapid acclimation), dry mouth, decreased appetite (especially at lunch), possible end-of-day crash, and rarely diarrhea.
   • Counselled on the importance of hydration due to increased dehydration risk.
   • Advised to contact the office if the pharmacy does not have the medication due to a national stimulant shortage, as controlled substances cannot be transferred.

4. Counseling:

   • Patient is actively seeing a counselor; workplace issues were extensively discussed during the session.

5. Follow-up:

   • Scheduled return appointment on November 19, 2024, at 2:30 PM (approximately two weeks).
   • Follow-up will include a review of pharmacogenomic testing results and assessment of the patient’s response to the Concerta trial.
   • Patient instructed to call the office with any concerns before the next appointment.

Additional Documentation

• Informed Consent: Discussed treatment options and potential side effects; patient consented to pharmacogenomic testing and medication trial.
• Risk Assessment: Reviewed medication risks and benefits; no current suicidal or homicidal ideation noted.
• Signature/Date:
  • Provider: Michael McDowell
  • Date: 11/5/2024

Quality Grade: High

Additional Questions for Improvement:

1. Would the inclusion of vital signs (if available) be beneficial for future documentation?
2. Is there any additional detail regarding the patient's past medical or family history that could be relevant to treatment decisions?
3. Are there any specific elements of the patient's social support system that should be further explored in subsequent visits?