CASE PRESENTATION NIMHANS -I.pptx

case on pms

1. CASE PRESENTATION-I Name : Mrs Bemina J A Mobile number :9886675333 Email :[email protected] 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 HISTORY COLLECTION

3. Irritable and crying spells Unable to be happy Abdominal Pain Cramps Profuse sweating, palpitation Weight gain Severe bleeding 15-20 pads/day CHIEF COMPLAINTS

4. Onset :Insidious onset Precipitating Factor : Monthly Periods Course : Every month before periods and subsides after Duration of Illness : 4 years HISTORY OF PRESENT ILLNESS

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 PAST MEDICAL HISTORY

6. Birth and Early Development: Her miles stone development is normal Behavior During Childhood: Nothing significant PERSONAL HISTORY

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 PERSONAL HISTORY CONTINUED

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 . PRE-MORBID PERSONALITY

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 PHYSICAL EXAMINATION

11. Temperature :96.8 F Pulse :115/ bpm Respiration :24/min Blood Pressure:110/70mmHg VITAL SIGNS

12. SKIN Color : Fair Condition : Normal Temperature : Warm Pigmentation : Absent Edema : Nil NAIL Color :Pink in color Clubbing :Nil Cyanosis :Nil INTEGUMENTARY SYSTEM

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 SPECIAL SENSES

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 Ears and Hearing:

16. Appearance : Symmetrical, Mucous Membrane :Pink in color, no obstruction , discharge Allergies: Nil Sinuses: Normal, no pain or tenderness present Nose and Sinuses:

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 Mouth and Throat Lips

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 NECK

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 RESPIRATORY SYSTEM ( THORAX AND LUNGS )

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 Mental Status Examination:

25. Current Management or Proposed Management Pharmacological: Tab Fluoxeine 20mg od Tab P yridoxine 100mg bd , T ab A lprozolam 0.5mg bd , T ab B romocriptine 25mg od Non-pharmacological Interventions Tried: TRIED? HELPFUL? Psycho education Yes Yes Motivational Interviewing Yes Yes Relaxation Strategies Yes