Case Summary:
You are Elaine Stuart, a 55-year-old former math teacher. This visit occurs about 5+ months after initial office visit with rectal bleeding. You are having progressive symptoms, becoming increasingly weaker, and are still having difficulty with pain. You enrolled in Hospice four days ago on June 8th.

Why You Are Seeing The Doctor Today:
You are seeing the resident today as a follow-up visit to evaluate your symptoms and discuss pain management.

Opening Statement:
In order to start all of the encounters in a similar manner, your opening statement should be about how you’ve been feeling. 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: "I was feeling OK for awhile, the pain seemed to be pretty much in control, but this last week has been just awful.

Physical Description:

• Looking quite tired (no makeup).

• You are tired, weak and uncomfortable. You are in pain and very fatigued. You are a bit agitated because you are not able to keep up with things around the house.

• You had been generally in good health until about 6 months ago when you noticed rectal bleeding.
• No allergies.
• No hospitalizations prior to this illness except for a tonsillectomy at age 9.
• Surgeries: Tonsillectomy at age 9 and bowel resection 3 months ago.
• No surgeries before 4 months ago except for the tonsillectomy as a child.
• No serious prior illnesses except for pneumonia in 1980.
• Immunizations up to date.

You have continued to experience some nausea that makes you uncomfortable.

Additionally:

• Your pain had been constant and diffuse; it is now more localized in the lower left quadrant of your abdomen and the pelvic area.
• The pain is generally worse after eating.
• You have been taking immediate release morphine intermittently for the abdominal pain; you take it inconsistently because it makes you "feel like a zombie."
• You are very ambivalent about taking the morphine since you are worried about becoming addicted to it. Consequently, you wait and wait to take it, until you can no longer stand the pain (it is about a 9 out of 10 at this point).
• After you take the morphine, the pain is reduced to a 4/10.
• You have been eating little lately (because of nausea); have not had any solid food for 2 days.
• You have not had a bowel movement in 5 days. This makes the pain worse and is the reason you are nauseated again. You haven’t been alarmed about not moving your bowels since you have not eaten much lately.
• You have lost 7 pounds in the last month, a total of 20 pounds through the course of the illness.
• Because you have been feeling even more fatigued, you are unable to do any housework and this upsets you.
• You have very little social support, so you have started seeing a counselor through Hospice, which seems somewhat helpful.

• Prescription Medication: Immediate release morphine as needed, in pill form (MSRI, or morphine sulfate, immediate release).

• Percocet (one tablet every 4 hours) was prescribed on 5/15/98.
• On 5/21/98, you called the office because of increased pain; dosage of Percocet increased to two tablets every 4 hours.
• On 6/3/98, the morphine sulfate above was prescribed.
• Over-the-Counter Medication: None.

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.

• You are afraid of becoming addicted to the drugs you are taking. You fear that you will become "out of control."
• You are upset because you can’t manage some things on your own any longer - housework, shopping and personal care. You know that Hospice will help with some of this, but you still need reassurance since you’ve only been enrolled a few days.
• You are concerned about who will take care of your cat. You worry about what will happen to her when you are gone.
• You are also concerned about who will handle your affairs if you are too incapacitated to do so; you have a little bit of money saved, don’t know how to handle this kind of thing.

You agree to any follow up plans the resident suggests.