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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Differentiate between the clinical presentation and diagnosis of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

  • Identify the desired therapeutic outcomes for patients with PMDD.

  • Design an appropriate therapeutic plan for a patient with PMDD.

  • Design an appropriate monitoring plan for a patient with PMDD, considering patient-specific factors.

  • Educate patients and other healthcare professionals about PMDD and therapeutic options.

PATIENT PRESENTATION

Chief Complaint

“I think my boss may fire me if I don’t get some help.”

HPI

Gloria Gray, a 29-year-old woman, is an established patient at the family medicine clinic who returns with complaints of bloating, breast tenderness, angry outbursts, irritability, depression, and fatigue. She has kept a record of her symptoms over the past 3 months, and it appears that her symptoms occur during the last week of her menstrual cycle each month. During this time, she has a difficult time at work. She gets angry easily and yells at coworkers. She feels very fatigued during this time, which causes her to lose focus and fall behind on her work. She is really concerned that she may lose her job. In addition, even though her husband has been very patient with her during these episodes, she can tell that it is negatively affecting their relationship because they argue more frequently. She has tried over-the-counter ibuprofen and Midol Teen, but these agents helped only minimally. Her symptoms typically resolve within the first few days of her menses. She says that she is depressed about her current situation, and she would really like some help. On an additional note, she states that she and her husband are not ready to have children as they previously thought. She says that there has just been too much stress in their lives lately, so she is interested in taking birth control. She and her husband use condoms but want to take every precaution currently to effectively prevent pregnancy.

PMH

Migraines without aura

Irritable bowel syndrome

FH

Mother has dyslipidemia. Father has irritable bowel syndrome.

SH

Married for 4 years. No children. Previous smoker 10 years ago, but no current tobacco use. She drinks alcohol socially on the weekends. She works full time as a professor at a small community college.

Meds

Metamucil one teaspoonful of powder in 8 oz of water daily

Propranolol 20 mg PO Q 6 H

Sumatriptan 100 mg PO PRN migraine headache, may repeat × one dose

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