Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
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The case of NICOLÃS is stated below.
CASE of NICOLÃS
Intake Date: November 2020
A 27-year-old Hispanic male student was referred for a psychiatric consultation after a workup for gastrointestinal distress proved negative. Nicolάs has consulted his family physician after months of feeling bloated and nauseated.
History of Present Illness:
Nicolάs described 3 years of “anxiety attacks” accompanied by palpitations, shortness of breath, hot flashes, sweating and parathesias, in addition to abdominal discomfort. Their onset is unclear, but Nicolάs remembers always being concerned about everything in his life and one time being very worried about a blind date arranged by a close friend. The week before the blind date he felt extreme nausea and did not know what to wear, concerned about what he was going to say, what if she did not like him. His friend forced him to go through with the date, but Nicolάs was extremely nervous and preoccupied throughout, took his date home immediately after the movie was over and sped away without even walking her to the door.
Nicolάs has continued to think about this situation and feels down when thinking of what happened. He wondered if he said the right thing, would her parents like him, etc. He thinks about these things all the time.
PAST PSYCHIATRIC HISTORY:
Over the past several months Nicolάs’ mood has been low, and he has had trouble staying asleep at night. Although he had always concerned himself about many situations that he really did not have control over things seem to be worse now. Nicolάs recalls he was a worry wort in high school really concerned about his grades. He wanted to work and do well in school but was unsure if he could do both. In high school he was concerned about having friends and extra-curricular activities.
SUBSTANCE USE HISTORY:
Nicolάs drinks socially. He denies any illicit drug use.
PAST MEDICAL HISTORY:
Nicolάs has been to many primary care doctors and specialists for his stomach problems. He is taking Stelara for colitis. He also thinks he has IBS, but the doctors have not confirmed that yet.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:
Nicolάs reports his mother is a worried wart and is very nervous. He does not want to be like that.
CURRENT FAMILY ISSUES AND DYNAMICS:
Nicolάs reports a very good relationship with both his parents and his siblings. The family is very close. Mom is the “ultimate” mother from Nicolάs’ point of view. Always concerned about her children and their needs. program he had to go for job interviews, these began to cause anticipatory anxiety. Nicolάs was hired by a large municipal welfare agency and stays mostly to himself on the job. He concerns himself about his performance and does not want to lose his job. Nicolάs finds himself being more challenged now because he is forgetting things at work and is having difficulty focusing.
MENTAL STATUS EXAM:
Nicolάs looks his stated age. He is oriented to time place and person. He denies suicidal and homicidal ideation. Nicolάs reports that he feels on edge all the time. This has been present since high school. He believes he sort of has gotten used to it.