Scenario 2, Part 1 of 3

Excerpts from the medical record:

Office record of Dr. Piper from eight years ago
"…has had 5 pregnancies…had great deal trouble…prolapsing hemorrhoids… about 12 years ago had hemorrhoidectomy… has had no further symptoms…prolapse…however…last 2-3 years…intermittent slight amounts rectal bleeding with bowel movements…is very concerned about…tumor or some other problem…despite fact PCP has seen regularly and done sigmoidoscopy once a year. On examination…no residual internal hemorrhoids…has small external hemorrhoidal tags…some scarring between them…think this is source of bleeding. Have told her…don't think anything could or should be done for this…will continue to see PCP for regular checkups."

Letter of Dr. Piper to Mrs. Owens' PCP following above exam
"… saw me June 4th…doesn't seem…recurrence…internal hemorrhoids…only abnormality found…three external tags…area…scarring with thinning overlying skin…mucosa…is probably site of her occasional rectal bleeding.…don't think anything…needs or should be done for…present problem…I have as you had suggested emphasized how important it is for her to see you once a year for rectal exam and occasional sigmoidoscopy…don't believe anything further needed."

Office record of Dr. Piper from four years ago
"…has come in because she's had some slight rectal bleeding recently. In fact was advised have sigmoidoscopy done…was following that that bleeding occurred. Generally has no rectal or colon problems or symptoms. On anoscopy and rectal exam…small hemorrhoids as before…no other abnormalities. Asked me if…thought annual sigmoidoscopy was necessary…told her thought there was good reason for it, although didn't necessarily insist on it for my patients. She thinks she might come back here in…couple years for repeat examination…"

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