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.

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

19.  Shape and Symmetry :Normal
 Temperature :Normal
 Tenderness :Absent
 Tactile Fremitus : Present bilaterally
 Breath Sounds :Normal vesicular breath sounds
present
 Movements :Symmetrical chest movements bilaterally
 Respiratory Rate:20/min

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

25. Current Management or Proposed Management
 Pharmacological:
 Tab Fluoxeine 20mg od
 Tab Pyridoxine 100mg bd,
 Tab Alprozolam 0.5mg bd,
 Tab Bromocriptine 25mg od
 Non-pharmacological Interventions
Tried: TRIED? HELPFUL?
 Psycho education Yes Yes
 Motivational Interviewing Yes Yes
 Relaxation Strategies Yes