Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with cyclic symptoms occurring during the luteal phase of the menstrual cycle, resolving shortly after menses onset. Symptoms include [mood swings/irritability/anxiety], physical complaints of [breast tenderness/bloating/headache/fatigue], and functional impairment in [work/social/home] settings. Symptoms documented over [number] cycles. No evidence of underlying psychiatric disorder or endocrine dysfunction.
Clinical Examination Findings
General physical examination is unremarkable. Pelvic examination reveals no structural abnormalities, adnexal masses, or cervical tenderness. Breast examination shows [no palpable masses/mild diffuse nodularity consistent with cyclic changes]. BMI is [value]. Vital signs are stable. Patient appears [euthymic/anxious/irritable] during current assessment.
Treatment Protocol
Initiate lifestyle modifications including aerobic exercise, dietary adjustments (reduced caffeine, salt, and alcohol), and stress management. Recommend supplementation with [Calcium/Magnesium/Vitamin B6]. Pharmacotherapy options discussed: [SSRIs (e.g., Fluoxetine/Sertraline) for luteal phase or continuous use / Combined Oral Contraceptives / NSAIDs for physical symptoms]. Follow-up in [timeframe] to assess symptom response.