After many years of teaching clinicians at all levels, I’ve come to the conclusion that you can’t beat the term putting it all together as our primary clinical objective. In the past few chapters, we showed you the importance of considering the history, past medical history, and active medications list; performing a good physical examination; evaluating the rhythm strip and 12-lead ECG; looking at the labs; performing ancillary tests; and creating a solid list of possibilities for the differential diagnosis.
The differential diagnosis is an essential part of any workup. You need to look at every possible cause for the patient’s present clinical state. Remember, if you don’t think of it, you can’t diagnose it. If you can’t diagnose it, you can’t treat it.
If you take away only one thing from this chapter, let it be this: You should never interpret a rhythm strip or a 12-lead ECG in a vacuum. You need to interpret it based on the entirety of the clinical presentation. We do not feel that there is a better bedside test at our disposal. It provides us with tons of useful clinical information about the heart and its rhythms. However, it is just one piece of the puzzle. To be sure, the clinical usefulness of this test increases dramatically when it is interpreted in the light of the clinical scenario.
Once you have accumulated the data and made a preliminary differential diagnosis, your next step is to determine the clinical stage of the patient. Is the patient emergent, urgent, or nonurgent? Your workup and treatment plan should be made in conjunction with the patient’s stage. Use your time wisely and be aggressive in the evaluation and treatment of any hemodynamically unstable rhythm. Don’t wait until it is too late to start treating the patient.
Finally, I can’t pass up the chance to reinforce one of my strongest beliefs about clinical medicine: Always follow your clinical gut! Call it intuition, guidance, voodoo, or whatever you want to call it, but we all have an innate ability to look at something and “feel” whether it is good or bad, right or wrong, the answer or the distraction. Think of it as your unconscious mind communicating with you about things it is noticing but you are failing to see. If you use it, it will get stronger. If you don’t, you will have one less tool available.