ICE Session Facilitation Notes

Task (1) List of Symptoms, Risk Factors or

Exposure (pertinent points)

Processed List

1. The heavy periods started 4 months ago

Menorrhagia

2. She uses tampons and pads together 6each/day

Menorrhagia

3. She is currently sexually active with no pain or

bleeding during intercourse
4. She feels tired most of the day and lightheaded with
physical activity

Anemia

5. Menarche at 12, regular, last about 5 days and has

had occasional heavy bleeding using 3 pads/ day
6. She was pregnant three years ago but miscarried at 8
weeks

History of Miscarriage

7. No hx of STIs
8. Mother has hypertension and uterine fibroids for
which she had an hysterectomy
9. She is a non-smoker, consumes 1 glass of wine/night,
10. Has had 5 sexual partners in her life, uses condoms
with her spouse and is monogamous

List of Physical (pertinent findings)

Family history of uterine fibroid

Pelvic examination
o Speculum examination
o Bimanual palpation
o Rectovaginal examination

HEENT
o Conjunctiva
o Mucous membranes

Pertinent Physical
Examination
Inspect the external genitalia
Perform Speculum examination
Perform Bimanual palpation
Perform Rectovaginal examination
Inspect the conjunctiva for pallor
Inspect mucous membrane for
dehydration

Uterine Fibroids

Adenomyosis

Endometrial Cancer

Task (2) Illness script

Epidemiology
Middle aged female
Previous miscarriage
Family history of fibroids
Temporal Course
Chronic
Syndrome Description
Menorrhagia, Fatigue and light headedness

Sample of Patient (SOAP) note

SUBJECTIVE

CC: My periods have become really heavy for the past four months

HPI: Patient presents for evaluation of heavy periods for the past four months. One week ago the patient had a very
heavy period in which she required the use of multiple pads and tampons. Prior to this episode she notes regular
periods every 28 days lasting about 5 days in length. She denies any pain and intermenstrual bleeding associated
with these episodes. There are no relieving or exacerbating factors. ROS is remarkable for fatigue and lightheadedness

OB/GYN: LMP was one week ago. Menarche at age 12, regular and used 3 tampons/day before the symptoms started.
There is a history is miscarriage at 8 weeks which occurred three years ago. Last pap smear and breast exam was six
months prior.

SEXUAL: She is currently in a monogamous relationship with her husband, uses condoms, no hx of STIs. She has had
five sexual partners in the past.

Allergies: none

Medications: multivitamins

PMHx: She has had a dilation and curettage for miscarriage 3 years ago.

FAMhx: hypertension and uterine fibroids in the mother.

Social: Non-smoker, drinks one glass of wine occasionally, and has no history of drug use. Accountant.

Objective History
Vital Signs: T 98.6 BP 100/70, PR 70, RR 14
General Assessment: middle-aged anxious woman in no acute distress
Primary system: Female Genitourinary

Vaginal mucosa without lesions or exudates, cervix without lesions or masses, cervical os closed with scant blood
present in the vaginal vault. Bimanual examination without enlargement, masses, or nodularity. Rectal
examination with appropriate tone and without palpable masses.
Additional Systems to examine
- HEENT: pallor

DATA INTERPRETATION (ASSESSMENT):

Diagnosis #1: Uterine Fibroids
HISTORY FINDING(S)

PHYSICAL EXAM FINDING(S)

Menorrhagia
Fatigue
Light headedness
Family history of uterine fibroid

Anemia

Diagnosis #2: Adenomyosis

HISTORY FINDING(S)

PHYSICAL EXAM FINDING(S)

Menorrhagia
Fatigue

Anemia

Lightheadedness
Diagnosis #3: Endometrial Cancer
HISTORY FINDING(S)

PHYSICAL EXAM FINDING(S)

Menorrhagia
Fatigue
Light headedness

Anemia

DIAGNOSTIC STUDY/STUDIES : (PLAN)

CBC
Ultrasound
Endmotrial biopsy