Nursing.

Demographic information

The client is aged 23 years old, and she is from a Caucasian family living Portland area in West Memphis. The client has no children. The native language she speaks in English, but she is noted to understand some Spanish. The client's arrival in the hospital was through a vehicle that she is presently financing. She has a master's degree in human resource management. Her employer referred her due to recurrent absences, and he also noted a lack of interest in her responsibilities and position. The client is a Christian in religion and regularly attends catholic mass events.

Presenting problem

"During the past few weeks, I have been excessively tired sad. My appetite has also been low. The situation occurs when I am generally outgoing or bubbling, and I want to feel a little bit better.

History of present illness

The client has been experiencing tiredness and feeling sad. The client has also lost appetite over the past few weeks, and there is no improvement despite her family efforts. Her situation occurs daily, but there are no signs of getting worse. She has focused on hanging out with her friends the previous nights, and she is having an excessive amount of drinks. She took a day off to rest and forced herself to eat something. However, she recorded no improvements on symptoms the day after and ever since. Her parents and friends sparked concern about her not behaving as usual and her friends asking if everything was okay. Her employer also called her due to other employees' and customers' complaints due to lack of interest, appearance, and attitude, and she was later informed not to return to work.

Past psychiatric history

the client has ever been diagnosed and has a history of insomnia over the last five years. There is also a history of severe mental retardations, microcephaly, developmental delays, and spastic quadriplegia. There is also depression as she tries to adapt to her incoming norm. She usually sees her psychiatrist for medication adjustments and follow-ups.

Substance use history

The client has no long history of substance abuse until last month. Due to her situation, she decided to hang out with her friends, smoked and drunk. There is also a significant recorded abuse of opium.

Developmental history

The client had been diagnosed with microcephaly in utero (Beyers et al., 2017). Her mother admitted that her family had children who are microcephalic in their history. The client is independent in all her aspects of living.

Family psychiatric history

The mother admitted that her family has a history of bearing microcephalic children.

Psychosocial history

The woman client works on full-time bases to cater to her needs and help her parents raise children.

History of trauma and abuse

The client admitted that her fellow employees were abusing her due to her condition and lack of job interests. She felt traumatized when the employees reported her to the seniors and got her fired.

System review

There are no issues with breathing and the expiratory system. Movement is upright, but his brain is malfunctioning.

Physical assessment

She had a temperature of 26 degrees. The heart was beating at the usual rate. The blood pressure was normal at eighty (Turns et al., 2019). She had no pain experiences. She weighed 65 kg.

mental status exam

she was very sad and In low moods. She was not very attentive, and there was a low level of consciousness. Her thoughts were every day, but she was mentally affected by losing her job.

Differential diagnosis

There can be a possibility of mental illness disorders since the lady experienced sadness, anxiety, and sleeping problems.

Treatment plan

Plan for Judith Alice was born on 22nd March 1991. She has been malcephalic and is diagnosed with depression and mental disorder for two years. She has been taking the dosage of pain killers and amoxicillin. The problem is tiredness, sadness, and anxiety. The plan aims to make the patient reduce the frequency, intensity, sadness, and fear. In the long term, the patient may practice anxiety management strategies.

Family genogram

Judith family

Mother: Lorin