Best Practices in Managing Patients with Confusing Narratives

Discuss best practices in managing this scenario in the context of the focused history and physical examination encounter. Support your response with a minimum of two APRN-approved scholarly resources. **Situation from the reading attached. **Please use this example and use sources from the list of acceptable sources provided.
***SITUATION***
Patient with Confusing Narrative
Some patient stories are confusing and do not seem to make sense. Just as you develop a differential diagnosis from the symptoms of the Present Illness, keep several possibilities in mind as you assess why the story is confusing. It may be the patient’s style, and by using your skills of guiding questions, clarification, and summarizing, you can put together a coherent story. Watch for an underlying issue; however, that is interfering with communication.
Some patients present a confusing array of multiple symptoms. They seem to have every symptom that you ask about, or “a positive review of systems.” With these patients, focus on the context of the symptom, emphasizing the patient’s perspective (see pp. 44–50), and guide the interview into a psychosocial assessment.
At other times, you may feel baffled and frustrated because the history is vague, and ideas are poorly connected and hard to follow. Even with careful wording, you cannot prompt clear answers to your questions. The patient may seem peculiar, distant, aloof, or inappropriate. Symptoms may seem bizarre: “My fingernails feel too heavy” or “My stomach knots up like a snake.” Perhaps there is a mental status change like psychosis or delirium, a mental illness such as schizophrenia, or a neurologic disorder. Consider an acute confusional state or delirium in acutely ill or intoxicated patients and dementia in the older adult patient. Their histories are inconsistent, and dates are hard to follow. Some may even confabulate to fill in the gaps in their memories.
If you suspect a psychiatric or neurologic disorder, gathering a detailed history can tire and frustrate both you and the patient. Shift to the mental status examination, focusing on the level of consciousness, orientation, memory, and capacity to understand. You can ease this transition by asking questions like “When was your last appointment at the clinic? Let’s see . . . that was about how long ago?” “Your address now is . . .? . . . and your phone number?” You can confirm these responses in the chart or ask permission to speak with family members or friends to obtain their perspectives.
LIST OF APPROVED REFERENCES:
• Textbooks used in your courses
• Peer-reviewed journal articles:
o New England Journal of Medicine
o Diabetes Educator
o Journal of the American Association of Nurse Practitioners
o UpToDate with an author
Epocrates – Drug information only