Case Summary:
You are Elaine Stuart, a 55-year-old high school math teacher. You are in the doctor’s office today because of a history (since December 1997) of rectal bleeding. You had been in your usual good health until one month ago when you noticed a small amount of red blood in the toilet.

Why You Are Seeing The Doctor Today:
You have come to the doctor’s office today because you are concerned about some rectal bleeding.

Opening Statement:
In order to start all of the encounters in a similar manner, your opening statement should be about the rectal bleeding. It’s hard to predict what the resident will say when he/she comes in the room; your response should be appropriate to the resident’s statement or question. For example:

The resident may ask you, "How are you doing, Ms. Stuart?"

• You would respond: "OK, but I’ve been having some bleeding that has me concerned."

• Well-groomed, dressed in a dressing gown ready for a physical exam (abdominal exam and blood pressure).

• You appear to be fairly calm, even though you are a bit anxious about the bleeding; you’re used to "handling" your emotions/keeping your cards "close to your chest."
• You look the resident in the eye.

• You have been generally in good health.
• Last seen by the doctor in January 1997, for an initial history and physical. At that visit, you were given a "clean bill of health."
• No allergies.
• Only hospitalization for a tonsillectomy at age 9.
• Surgery-tonsillectomy as a child.
• No serious illnesses except for pneumonia in 1980.
• Immunizations up to date.
• GYN/OB: Normal history; menopause 2 years ago at age 53; you see your gynecologist for routine care; had a Pap smear, rectal exam, and stool analysis 6 months ago which were normal. A mammogram 2 months ago was normal.

You have been in good health until one month ago when this bleeding began.

• Your current symptoms began about four weeks ago when you first noticed a small amount of bright red blood in the toilet following a bowel movement. It was difficult to quantify the amount of blood because it was diluted in the toilet bowl. There was not much blood on the toilet paper.
• The bleeding occurred intermittently (about every third bowel movement) that week, then seemed to disappear for a week.
• Two weeks ago, the bleeding began again and has persisted, occurring with each bowel movement.
• In the last 2-3 days, the bleeding seems to have increased. This morning you noted that your bowel movement was moderate and colored dark red.
• You do not have any abdominal pain.
• Your only other symptom has been minor fatigue over the last 2 weeks.
• You see your gynecologist yearly for a routine pap smear; you also have a mammogram every 1-2 years.

• Prescription Medication: None. This is what you will answer when asked, "Are you on any medication?"
• Over-the-Counter Medication: Over the counter vitamins. Aspirin for occasional joint pain. This is what you will answer when asked, "Do you take any over-the-counter medicine?"

NOTE:You do not at present have a health care proxy. The resident should ask you about this. A health care proxy is a document which designates an agent to act on your behalf should you become incapacitated in some way and unable to make medical/health care decisions for yourself. The resident should discuss the need for you to designate an agent during this visit. Your response will be that this was discussed a year ago and you never did anything about it. As the resident reviews this matter with you, your responses during the discussion should include:

• You wonder if it needs to be a relative (you have no family that you are close to; your brothers live out of town)
• You ask if the physician can serve as your proxy, since you have no close friends (the resident should respond that it isn’t a good idea, although it is possible).
• You then say that you have someone in mind (your upstairs neighbor) but you need to talk to her first.
• The resident should encourage you to designate an agent for proxy and provide another copy of a proxy description to discuss with you.

IMPORTANT: If the student does not ask you about health care proxy, you will bring the subject up, saying:
"At last year’s visit, we talked about health care proxy, but I didn’t get around to doing anything about it. Do you have another form?"

• Encourages you to identify who will make decisions for you, AND
• Outlines the risks involved in not having a proxy (your response will be that you don’t have a good friend to do this for you), THEN

Personal Habits:
Alcohol Use: A glass or two of wine on weekends.
Tobacco Use: None.
Caffeine Use: 2 cups of coffee a day.
Drugs (Illicit): No history of illicit drug use.
Vitamins: Take "One a Day," one tablet per day; occasional aspirin for joint aches.
Exercise: You don’t have time.
Health Insurance: You are covered under your school’s Independent Health Association Plan.

• You will respond the same to all interviewing styles.

"What are you most concerned about?" "I’m kind of worried about this bleeding. Doesn’t it usually mean cancer?"
(You will ask this if the student has not already covered it/reassured you on this point.)

• "Does the health care proxy need to be a relative?"
• Could the physician serve as my health care proxy"
• Can I wait and think about this? I have someone in mind, but I need to discuss it with her first."