Mrs. Bemina J A, a 38-year-old married Muslim woman, presented with symptoms of premenstrual syndrome including irritability, crying spells, abdominal pain, and severe bleeding for the past 4 years. Her physical exam and medical history were unremarkable. She reported relationship issues with her husband due to her mood changes and inability to work or concentrate due to emotional instability and pain. She was started on fluoxetine, pyridoxine, alprozolam, and bromocriptine and found psychoeducation and motivational interviewing to be helpful.
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Managing PMS with Medication and Lifestyle Changes
1. Name : Mrs Bemina J A
Mobile number :9886675333
Email :beminaja@gmail.com
Date :24/03/23
2. 1.IdentificationData:
Name :Mrs..
Age :38years
Sex :Female
I.P.No :32300686
Education :MBA
Occupation :HR
Family Income :Rs.10,000/month
Marital Status :Married
Religion :Muslim
Diagnosis :Premenstrual syndrome
3. Irritable and crying spells
Unable to be happy
Abdominal Pain
Cramps
Profuse sweating, palpitation
Weight gain
Severe bleeding 15-20 pads/day
4. Onset :Insidious onset
Precipitating Factor : Monthly Periods
Course : Every month before periods
and subsides after
Duration of Illness : 4 years
5. a. Mental Illness :No past mental illness
b. Medical and Surgical History: Nothing significant
c. Negative History : disturbance in relationship ,social
withdrawal present , unable to concentrate in work
palpitation ,anger low self eseemed emotional instability
d. Legal Issues :No legal issues
e. Substance Use : Excessive intake of caffeine
6. Birth and Early Development:
Her miles stone development is normal
Behavior During Childhood:
Nothing significant
7. Occupation:
she started to work in 2019 and worked for 2 ½ years.
she could not work further due to her emotional
instability and sever abdominal pain.
Sexual and Marital History:
She is married and has 2 children was sexually active
Since 4 yrs due to mood changes not in good terms in
relationship
Substance Use History:
No substance abuse is present. Drinks coffee at least 8
times a day
8. Social Relationships :she was maintaining good
relationship with family members, friends and
coworkers ,neighbors.
Intellectual Activities : Her academic performance
was good and had good memory and observation
skills.
Character: she is very spiritual and jolly kind of
person always preferred to be with friends and outdoor
.
9. Inter-personal Relationships
She was assertive , confident, person and enjoy being
with friends and also maintains good rapport
Energy and Initiative :
She was active and helped her mother in law in household
activities.
Fantasy Life :
Nothing significant
Hobbies/Habits :
She is interested in craft making ,collection of old coins
10. GENERAL APPEARANCE
Body Build : Well built
Hygiene and Grooming : Fair
Level of Consciousness :Conscious
Activity :Not interested to carryout the
activities
Weight :64kg
Height :155cm
BMI :26.6 Kg/m2
11. Temperature :96.8 F
Pulse :115/bpm
Respiration :24/min
Blood Pressure:110/70mmHg
12. SKIN
Color :Fair
Condition : Normal
Temperature :Warm
Pigmentation :Absent
Edema :Nil
NAIL
Color :Pink in color
Clubbing :Nil
Cyanosis :Nil
13. FACE
Facial features are symmetrical. No marks, puffiness
and edema noted.
HEAD
Hair :
Black and grey in color and equally distributed
Scalp :No dandruff and pediculosis or wounds
14. Eyes and Vision : Symmetrical no swelling present
Eye Lids and Eyebrows : Pink in color
Conjunctiva : Normal, white in color
Sclera : Bilaterally equal and reactive to light
Pupils Vision : Vision field 6/6
Eye Ball Movements : Normal and present in all directions
15. Shape of the External Ear : Symmetrical and no
abnormalities present
Hearing :Hearing acuity is normal
Use of Hearing Aids :Nil
Other Complaints : No signs of infection, itching
and hot flash present, discharge, cerumen
16. Appearance : Symmetrical,
Mucous Membrane :Pink in color, no obstruction ,
discharge
Allergies: Nil
Sinuses: Normal, no pain or tenderness present
17. Lips :Pink in color , wet, no ulceration present
Teeth present :Alignment is normal, white in color
Gums : Pink in colour, no swelling present
Buccal Mucosa :Pink in colour, no swelling present
Tongue :Pink in color, no lesion and white
patches present
Tonsils :No enlargement and pain present
Uvula :Present in midline
Odor of Breath :No halitosis
18. Movements :Present in all directions, no stiffness
present
Pain : Absent
Jugular Vein : No distention present
Lymph Nodes :No tenderness and enlargement present
Thyroid Gland :No enlargement observed
20. CARDIO-VASCULAR SYSTEM
Auscultation : Heart sounds S1,S2 heard, no murmurs
present
Heart Rate:116/min
Blood Pressure:110/70mmHg
GASTRO INTESTINAL SYSTEM
Abdomen: Normal bowel sounds present. No tenderness,
organomegaly, ascites present.
GENITO URINARY SYSTEM
History of frequency in urination present.
No dysuria, incontinence, dribbling and urgency present.
21. MUSCULOSKELETAL SYSTEM
Mobility of Joints :ROM exercises in all joints present
Gait and Posture : Normal and erect
Muscle Tone :Normal,5/5
Ability to perform ADL: Able to perform ADLs but no
interested to do
BACK
No kyphosis, scoliosis and lordosis present. No spinal
swelling
22. NERVOUS SYSTEM
Mental Status : She is conscious , alert and oriented to
time ,place and person
Cerebellar Function :Motor skills of coordination,
balance and gait are normal
Sensory Function :She is able to feel, see, hear, smell
and taste.
23. Reflex Function:
Biceps ++
Triceps ++
Patellar ++
Achilles Tendon ++
Plantar Flexion ++
Cranial Nerves: Normal functioning of 12 pairs of
cranial nerves
24. General Appearance & Behavior - Personal hygiene not
maintained , shabbily dressed, anxious
Mode of entry : came willing Cooperaive
Psychomotor activity - normal
Speech (tone/tempo/volume) - Speaks When Spoken,
slow ,soft
Mood - Irritable says sever pain
abdomen and legs , tears flow for no reason, not interested to
talk
Objective : on observation Irritable ,
anxious, worried
Thought - normal
Perception - no illusion
hallucinations
Cognitive functions - adequate
Judgment (Personal, Social and Test) - reasonable
Insight – Present