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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 Physician 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 really has a difficult time at work in particular. 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 really negatively affecting their relationship because they argue more frequently. She has tried over-the-counter ibuprofen and Midol Teen Formula, 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 they want to take every precaution at this time 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 Q 6 H Sumatriptan 100 mg PRN migraine headache, may repeat × one dose Women’s multivitamin daily All NKDA Physical Examination Gen Tearful, petite female VS BP 108/66 mm Hg, P 55 bpm, RR 17, T 98.3°F; Wt 112 lb, Ht 5′6″ Skin Normal; intact; warm and dry HEENT PERRLA; EOMI; moist mucous membranes; TMs intact Neck/Lymph Nodes Supple without evidence of JVD, lymphadenopathy, or thyromegaly Lungs/Thorax CTA & P Breasts Symmetric; no lumps or masses; nipples without discharge; tender to touch CV RRR without MRG Abd Soft, NT/ND; +BS; no masses Genit/Rect Normal pelvic exam and pap smear Ext Normal ROM; pulses 2+; No CCE Neuro A & O × 3; CN II-XII intact; DTRs 2+ Assessment 1. PMDD 2. Desire for contraception 3. Migraines without aura, currently well controlled 4. Irritable bowel syndrome, currently well controlled What symptoms in the patient’s clinical presentation indicate PMDD?

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