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he Confusing Patient. Some patients are confusing because they ave multiple symptoms. They seem to have every symptom that you ask out, or "a positive review of systems." Although they may have multiple edical illnesses, a somatization disorder is more likely. With these patients, cus on the meaning or function of the symptom and guide the interview into a psychosocial assessment. There is little profit to exploring each symptom in detail.

At other times you may be baffled, frustrated, and confused yourself. The history is vague and difficult to understand, ideas are poorly related to one another, and language is hard to follow. Even though you word your questions carefully, you cannot seem to get clear answers. The patient's manner of relating to you may also seem peculiar, distant, aloof, or inappropriate. Patients may describe symptoms in bizarre terms: "My fingernails feel too heavy" or "My stomach knots up like a snake." Using various facilitative techniques, try to learn more about the unusual qualities of the symptoms. Perhaps there is a mental status change such as psychosis or delirium, a mental illness such as schizophrenia, or a neurologic disorder (see Chapter 16, The Nervous System). Watch for delirium in acutely ill or intoxicated patients and for dementia in the elderly. Such patients give histories that are inconsistent and cannot provide a clear chronology about what has happened. Some may even confabulate to fill in the gaps in their memories.

When you suspect a psychiatric or neurologic disorder, do not spend too much time trying to get a detailed history. You will only tire and frustrate both the patient and yourself. Shift to the mental status examination, focusing on level of consciousness, orientation, and memory. You can work in the initial questions smoothly by asking "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 check these responses against the chart, assuming that the chart is accurate, or by getting permission to speak with family members or friends and then doing so.

The Angry or Disruptive Patient. Many patients have reasons to be angry: they are ill, they have suffered a loss, they lack their accustomed control over their own lives, and they feel relatively powerless in the health care system. They may direct this anger toward you. It is possible that hostility toward you is justified . . . were you late for your appointment, inconsiderate, insensitive, or angry yourself? If so, acknowledge the fact and try to make amends. More often, however, patients displace their anger onto the clinician as a reflection of their pain.

Accept angry feelings from patients and allow them to express such emotions without getting angry in return. Beware of joining such patients in their hos-lity toward another provider, the clinic, or the hospital, even when you are vately in sympathy. You can validate their feelings without agreeing with eir reasons. "I understand that you felt very frustrated by the long wait and answering the same questions over and over. The complex nature of our health care system can seem very unsupportive when you're not feeling well." After the patient has calmed down, you can help find steps that will avert such Csituations in the future. Rational solutions to emotional problems are not always possible, however, and people need time to express and work through their angry feelings.

_^Some angry patients become hostile and disruptive. Few people can disrupt ie clinic or emergency department more quickly than patients who are angry, elligerent, or uncontrolled. Before approaching such patients, alert the security staff—as a clinician, you have the right to feel and be safe. It is especially important to stay calm, appear accepting, and avoid being challenging in return. Keep your posture relaxed and nonthreatening and your hands loosely open. At first, do not try to make disruptive patients lower their voices or stop if they are cursing you or the staff. Listen carefully and try to understand what they are saying. Once you have established rapport, gently suggest moving to a different location that is not upsetting to other patients or families.

The Patient With a Language Barrier. Nothing will convince you more surely of the importance of the history than having to do without one. When your patient speaks a different language, make every possible effort to find an interpreter. A few broken words and gestures are no substitute for the full story. The ideal interpreter is a neutral objective person who is familiar with both languages and cultures. Beware of using family members or friends as interpreters—confidentiality may be violated, meanings may be distorted, and transmitted information may be incomplete. Untrained interpreters may try to speed up the interview by telescoping lengthy replies into a few words, losing much of what may be significant detail.

As you begin working with the interpreter, establish rapport and review what information would be most useful. Explain that you need the interpreter to translate everything, not to condense or summarize. Make your questions clear, short, and simple. You can also help the interpreter by outlining your goals for each segment of the history. After going over your plans with the interpreter, arrange the room so that you have easy eye contact and nonverbal communication with the patient. Then speak directly to the patient, asking "How long have you been sick?" rather than "How long has the patient been sick?" Having the interpreter close by keeps you from moving your head back and forth as though you were watching a tennis match!

When available, bilingual written questionnaires are invaluable, especially for the Review of Systems. First be sure patients can read in their language; otherwise, ask for help from the interpreter. Some clinical settings have speaker-phone translators; use them if there are no better options.

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